RANG’S

CHILDREN’S
FRACTURES
Third Edition
Dennis R. Wenger, M.D., Mercer Rang, M.D., and Maya E. Pring, M.D.
RANG’S
CHILDREN’S
FRACTURES
Third Edition

Mercer Rang, M.D.

Professor of Orthopedic Surgery
University of Toronto

Maya E. Pring, M.D.

Associate Staff—Orthopedics
Children’s Hospital—San Diego
Assistant Clinical Professor of Orthopedics
University of California—San Diego

Dennis R. Wenger, M.D.

Director, Pediatric Orthopedic Training Program
Children’s Hospital—San Diego
Clinical Professor of Orthopedic Surgery
University of California—San Diego
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Library of Congress Cataloging-in-Publication Data

Rang, Mercer.
Rang’s children’s fractures / Mercer Rang, Maya Pring, Dennis Wenger; foreword by Robert
Salter. — 3rd ed.
p. cm.
Rev. ed. of: Children’s fractures. 2nd ed. ©1983.
ISBN 0-7817-5286-8
1. Fractures in children. I. Pring, Maya. II. Wenger, Dennis R.
(Dennis Ray) III. Title. IV. Title: Children’s fractures.
[DNLM: 1. Fractures—Child. WE 180 R196r 2006]
RD101.R33 2006
617.1'5'083—dc22
2005007039

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10 9 8 7 6 5 4 3 2 1
 Contents
Contributors vii
Foreword ix
Preface xi
Acknowledgments xiii
Chapter 1 Children are Not Just Small Adults 1
Chapter 2 The Physis and Skeletal Injury 11
Chapter 3 Orthopedic Literacy: Fracture Description
and Resource Utilization 27
Chapter 4 Emergency Fracture Reduction 41
Chapter 5 Casts for Children’s Fractures 53
Chapter 6 Clavicle 75
Chapter 7 Shoulder and Humeral Shaft 85
Chapter 8 Elbow—Distal Humerus 95
Chapter 9 Elbow—Proximal Radius and Ulna 119
Chapter 10 Radius and Ulna 135

Chapter 11 Hand 151

Chapter 12 Pelvis and Hip 165
Chapter 13 Femoral Shaft 181
Chapter 14 Knee 201
Chapter 15 Tibia 215
Chapter 16 Ankle 227
Chapter 17 Foot 243
Chapter 18 Spine 253
Chapter 19 Fractures in Special Circumstances 271
Chapter 20 Accident Prevention, Risk, and the
Evolving Epidemiology of Fractures 293
Coda 305
Index 307
v
 Contributors
LCDR Jeffrey A. Cassidy
Medical Corps, United States Navy Reserves
Director of Pediatric Orthopaedic Services
Naval Medical Center, San Diego

Henry G. Chambers, M.D.

Chief of Staff
Children’s Hospital—San Diego
Associate Clinical Professor of Orthopedics
University of California—San Diego

CAPT Bruce L. Gillingham

Medical Corps, United States Navy
Director for Surgical Services
Pediatric Orthopaedic Surgeon
Naval Medical Center, San Diego

François D. Lalonde, M.D.

Associate Staff—Orthopedics
Children’s Hospital—San Diego
Assistant Clinical Professor of Orthopedics
University of California—San Diego

Scott J. Mubarak, M.D.

Director, Pediatric Orthopedic Clinical Program
Children’s Hospital—San Diego
Clinical Professor of Orthopedics
University of California—San Diego

Peter O. Newton, M.D.

Director, Scoliosis Program
Program Consultant, Surgical Research
Children’s Hospital—San Diego
Associate Clinical Professor of Orthopedics
University of California—San Diego

Philip Stearns, C.P.N.P.

Director, Nurse Practitioner and Physician Assistant Program
Department of Orthopedics
Children’s Hospital—San Diego

C. Douglas Wallace, M.D.

Medical Director of Orthopedic Trauma
Children’s Hospital—San Diego
Assistant Clinical Professor of Orthopedics
University of California—San Diego

vii
 Foreword
It was in 1955 that Dr. Walter Blount wrote his splendid CLASSIC entitled
Fractures in Children in which he emphasized that fractures in children were
definitely different from fractures in adults.
During the ensuing 50 years, numerous books on this important subject
have been written by eminent pediatric orthopedic surgeons. Of these books,
the most widely read as well as the most enjoyed have been the first and second
editions (1974 and 1983) of Children’s Fractures written solely by the late Dr.
Mercer Rang.
Tragically and poignantly, Dr. Rang passed away in October 2003 after a
courageous battle against a prolonged illness.
I deem it a special privilege to have recruited Mercer to the Orthopaedic
Staff of the Hospital for Sick Children in Toronto in 1967 where he became a
warm friend and an admirable colleague for the rest of his life. His most endur-
ing and endearing as well as appreciated quality was his remarkable skill as a
teacher through both the spoken and written word.
Prior to Dr. Rang’s illness, he and his good friend Dr. Dennis Wenger had
already co-authored a superb book entitled The Art and Practice of Children’s
Orthopedics. Also before Mercer’s illness, this pair of gifted teachers had already
begun the onerous task of co-authoring the third edition of Children’s Fractures.
Surely there can be no finer tribute to Mercer Rang than Dennis Wenger’s per-
petuation of this book with an additional author, Maya Pring.
Although neither the first nor the second editions contained a Foreword, the
Preface that Mercer wrote for the second edition was so delightfully typical of
his whimsical humor that I felt the first paragraphs should be included in his
memory in this Foreword:
A parable: The child in the back of the car has a broken arm. The driver
stops to ask directions, “Excuse me, can you tell me the way to the Children’s
Hospital, please?”
A well-meaning pedestrian steps forward to offer advice: “It’s really very
easy.” He begins to describe the usual way, rattling through the roads and land-
marks to be noted. Before this information has had time to sink in he begins
again with another route, “This is the best way; I read it in last week’s paper.”
He moves his hands to indicate turns and so on, before realizing that his
instructions have not been comprehended. “Well, perhaps you should take the
easiest route. It’s about 4 miles straight down the road.”
Directions about fracture care are a little like this.
Together, the late Dr. Mercer Rang and the current authors, Dr. Dennis
Wenger and Dr. Maya Pring, have created an outstanding book that is an en-
tirely appropriate successor to Mercer’s first two editions.
Woven throughout the tissue of this exemplary book is the thread of that un-
common sense, namely, common sense. As in the previous two editions, the
illustrations are impressive. Indeed, most of the line drawings were rendered by
Mercer Rang’s artistic hand.
Recent advances in the management of children’s fractures since the second
edition of Mercer’s book (1984) have been described in detail. Examples of such
advances include the initial cast treatment of femoral shaft fractures in infants
and very young children as well as the open reduction and internal fraction of
femoral shaft fractures in older children, the closed reduction and percutaneous
ix
 pinning of supracondylar fractures of the humerus, and the flexible intra-
medullary flexible nails for diaphyseal fractures.
Every person who treats children’s fractures will be enormously grateful to
the late Mercer Rang as well as to Dennis Wenger and Maya Pring for writing
this most admirable book. It should become an essential reference book in the
emergency department of every hospital in which children’s fractures are
treated.
This exemplary book is certainly a fitting memorial to the late Dr. Mercer
Rang.

ROBERT B. SALTER
Toronto

x
 Preface
The world of children’s fracture care has changed remarkably since the 1973
first edition of this textbook. When Mercer Rang was recruited from Kingston,
Jamaica, to the Hospital for Sick Children in Toronto in 1967, one of his as-
signments was to study fracture care in children. At that time, the only signifi-
cant textbook on children’s fractures was that of Walter Blount, which had last
been published in 1955.
Mercer Rang recognized this void and also understood that contemporary or-
thopedic residents needed to know more than the principles that Walter Blount
had espoused, if they were to provide state of the art care for children. (It should
be noted that Blount’s text said nothing about growth plate injuries.) The A-O
ideas from Switzerland made their first North American appearance in Canada
(especially Toronto and Montreal) in the late 1960s and early 1970s and Rang
was quick to recognize that some of their principles applied to children’s injuries.
This is particularly true of forearm fractures in children over age 10 who up until
that time had been primarily treated with closed reduction with almost any de-
gree of angulation accepted. It became apparent that older children had little po-
tential for remodeling and required adult treatment methods.
The first edition of this text briefly presented the tradition of children’s frac-
ture treatment and also presented new thinking and new ideas. Rang was able
to illustrate and explain children’s fractures in a way that was clearer and more
entertaining than anything that had been presented before. The success of the
text was immediate, becoming a standard reference throughout the orthopedic
world. This was further aided by Rang’s brilliant speaking style, which made all
who heard him speak want to buy the book.
A second equally successful edition was published in 1983. Several years had
elapsed before thought was given to a third edition. A significant impetus for
the third edition came from Mr. Robert Hurley, Executive Editor at Lippincott,
Williams & Wilkins, who felt that a practical textbook of this type should be
updated and continued. Although occupied with other pursuits, Mercer and I
had further discussions in response to Mr. Hurley’s request and made the deci-
sion to proceed. Work began in early 2002. By that time Children’s Hospital—
San Diego had a large clinical and research unit devoted to treatment of chil-
dren’s fractures, and it was decided that the revision of the text should be based
in our center with appropriate input from Toronto.
We decided on three authors to represent the eras of orthopedic experience: a
senior sage, an experienced intermediary, and the dynamic intellect and energy
of youth. Dr. Maya Pring, a native of Colorado and a graduate of the Mayo
Clinic orthopedic training program, completed her fellowship at Children’s
Hospital—San Diego and has been on staff here for several years. She brings a
level of experience, intellect, and energy to the subject of children’s fractures
that energizes this edition.
As in the first and second edition, this text is designed as a basic introduction
to the diagnosis and treatment of children’s fractures. It is not intended to be a
comprehensive reference and should not be used as such. To emphasize this, a
coda at the end of the text lists the many outstanding comprehensive children’s
fracture texts that are currently available and that provided valuable informa-
tion for this revision.

xi
 The book is designed for medical students, physician’s assistants, residents,
emergency room doctors, general orthopedists, and children’s orthopedists.
Many new features have been added. In the introductory chapters, we com-
ment briefly on the differences between children’s and adult’s injuries and also
discuss evolving trends toward efficient fracture treatment systems, many of
which are being developed in children’s hospitals in North America. Chapters 3
and 4 deal with practical matters of fracture description, fracture communica-
tion, conscious sedation methods and specific techniques for managing a safe,
high-volume fracture reduction system.
We have added a chapter on casts in children since we see so many problems
in this area and find that many physicians are not fully versed on the matter.
The diagnostic chapters try to present in a simple and practical way the most
common injuries in each of the anatomic areas in a child. We do not focus on
advanced techniques and rare problems. We close with a chapter on cultural
trends and the epidemiology of fractures that reviews fracture prevention efforts
and then presents reasons for the increasing incidence of children’s fractures in
North America.
The result is a third edition which we believe provides a concise, practical,
and contemporary view of children’s orthopedics. We have focused on a style
somewhere between that of a traditional orthopedic text and a typical college
textbook. I have always been struck by the friendliness and ease of use of con-
temporary textbooks used in high schools and universities and tried to emulate
them. Mercer Rang and I first worked on this approach in our textbook The Art
and Practice of Children’s Orthopedics.
In closing, I want to pay homage to my great mentor, Mercer Rang, who in-
troduced me to clear thinking and educational style as relates to all of children’s
orthopedics. Sadly, Mercer developed an illness and passed away in October
2003 and was unable to see the final rendition of this text. He was instrumental
in its planning and organization, writing and illustrating many of the chapters.
We are saddened by his passing and the world has lost both a kind man and an
orthopedic giant. I want to personally thank Helen Rang and her lovely family,
who have been both understanding and cooperative in this difficult transition.
We dedicate this text to the spirit of Mercer Rang, whose grace and style made
orthopedic education a brilliant art form.

DENNIS R. WENGER, M.D.

San Diego

xii
 Acknowledgments
We are grateful to our colleagues, both in Toronto and San Diego, for their
assistance and interest in revising this text. A special thanks goes to Robert
Salter in Toronto whose organizational skills, research efforts, and energy
helped to develop the Hospital for Sick Children in Toronto as one of the
world’s leading pediatric orthopedic centers. Also, our thanks to Drs. William
Cole and John Wedge in Toronto, who continue this spirit.
The fracture treatment philosophy, which evolved at the Hospital for Sick
Children in Toronto, is now widely used throughout the world. Children’s Hos-
pital—San Diego has greatly benefited from transmission of this knowledge,
and we fortunately have been able to expand and further develop the field. We
want to specifically thank our contributors, each who in some way have a con-
nection to our Toronto base.
Dr. Scott Mubarak had his fellowship training in Toronto and has continued
to have a strong clinical and research interest in all areas of children’s orthopedic
trauma. Dr. Bruce Gillingham was also a Toronto fellow with Mercer Rang, and
both he and Dr. Cassidy have strengthened this text with their chapter on spine
fractures. Our San Diego colleagues, Dr. Henry Chambers, Dr. Peter Newton,
Dr. Douglas Wallace, and Dr. François Lalonde (all trained by Hospital for Sick
Children—Toronto influenced staff ) have greatly strengthened this book, both
by co-writing chapters and by allowing us to use their cases to illustrate points.
A special thanks goes to Mr. Philip Stearns, a nurse practitioner at Children’s
Hospital—San Diego, who was the founding member and leader of a pioneer-
ing cadre of nurse practitioners and physician assistants who help provide effi-
cient fracture care in a new and innovative way. Philip has helped to write sev-
eral chapters and is a leader in defining a new field in orthopedic surgery. These
concepts are outlined in Chapter 4.
We also want to thank Mr. J.D. Bomar, the audio-visual coordinator in the
orthopedic department, who was responsible for all images and, more impor-
tantly, for much of the layout of this text. Also, we want to thank Karen Noble,
Administrative Assistant to Dr. Wenger in San Diego, whose intellect, work
ethic, and innate organizational skills were central to completing this project.
We also wish to thank Ms. Stacey L. Sebring, Developmental Editor at Lip-
pincott, as well as Mr. Robert Hurley, Executive Editor at Lippincott, who have
guided this process. We want to thank them not only for the traditional edito-
rial skills, but in addition for their allowing us the freedom to produce a text
with a layout that differs from traditional medical books.
We also thank our families for the time lost to them. Their understanding
that the creative process has great rewards, and sometimes “trumps” other activ-
ities, confirms their sophistication.
Finally, we wish to thank Helen Rang and her wonderful family for their kind-
ness, patience, and consideration as this project has evolved in a transitional period.

DENNIS R. WENGER, M.D.

San Diego
MAYA E. PRING, M.D.
San Diego
MERCER RANG, M.D.
Toronto (1926-2003)
xiii
 Children Are Not
1
Just Small Adults
Mercer Rang m Dennis Wenger

• Anatomic Differences 1
• Biomechanical Difference 2
• Descriptive Terms—Children’s Fractures 2
• The Physis 5
• Physeal Terminology 5
• Periosteal Biomechanics 7
• Physiological Differences 7

INTRODUCTION
Fractures in children differ from those in adults. Because the anatomy, biome-
“The most savage
chanics, and physiology of a child’s skeleton are very different from those of an
adult, in children you will see differences in fracture pattern, problems of diag-
controversies are
nosis, and treatment methods. This chapter introduces the many differences en- those about matters
countered when comparing children’s fractures to adult injuries.
as to which there is
ANATOMIC DIFFERENCES no good evidence
Much of a young child’s skeleton is composed of radiolucent growth cartilage;
thus often injury can only be inferred from widening of the growth plate or either way”
from displacement of adjacent bones on plain or stress films. The periosteum is
thicker and stronger and produces callus more quickly and in greater amount
— BERTRAND
than in adults. RUSSELL
1
2 BIOMECHANICAL DIFFERENCES
Children Are Not Just Small Adults
“Fractures in children differ
from those in adults”
Adult Child
Figure 1-1 Microradiographs of the dis-
tal radial diaphysis of an adult and of a child
8 years old. The haversian canals are larger
in the child. Children’s bones are more
porous than adults’.
Figure 1-2 Fracture types in children.
Biomechanics of Bone
Many years ago, it was thought that fractures were less common in children as
compared to adults because “the proportionate excess of the animal over the
earthy constituents” protected the bone and allowed it to bend instead of break-
ing. Subsequently, it has been determined that haversian canals occupy a greater
portion of the cortex, making young bone more porous (Fig. 1-1) and more
flexible than adult bone. In effect, a child’s bone is more like Gruyère cheese
than cheddar and can tolerate a greater degree of deformation than an adult’s
bone can.
The pores in the cortex of a child’s bone may limit the extension of a fracture
line in the same way that a hole drilled through the end of a crack in a window
will prevent the crack from extending. Compact adult bone fails in tension,
whereas the more porous nature of a child’s bone allows failure in compression
as well.
DESCRIPTIVE TERMS—
CHILDREN’S FRACTURES
The porous character of a child’s bone noted previously accounts for the various
fracture types (Fig. 1-2). The following commonly used terminology, although
somewhat overlapping (and not always agreed on), has become part of the es-
sential language of children’s fractures.
Fracture Severity Descriptions
Buckle or Torus Fracture Compression failure of bone produces a buckle
fracture, which is also called a torus fracture because of its resemblance to the
raised band around the base of an architectural column. These fractures occur
near the metaphysis, where porosity is greatest, particularly in younger children.
Disabled teenaged children, who do not bear weight and hence have porous
bones, may also sustain buckle fractures.
Traumatic Bowing of Bone Bending of bones, most commonly recognized in
the ulna and fibula, can occur without any evidence of acute angular deformity
(Fig. 1-3). If you try to break a child’s forearm, either postmortem or during
osteoclasis, you will find that the bones may be bent 45° or more before the tell-
tale sound of a fracture is heard. If you stop before the bone fractures, you will
Torus
“A buckle fracture is also called a torus fracture because of its resemblance to
the raised band around the base of an architectural column”
find that it will slowly, but incompletely, straighten itself out over several min- 3
utes. Such is the mechanism for traumatic bowing. Descriptive Terms—
This phenomenon has also been described as plastic deformation of bone. In Children’s Fractures
dogs, the bone deforms because microscopic shear fractures—at about 30° to
the long axis—develop on the concave aspect of the bone. Because there is no
true fracture there is no hemorrhage, no periosteal new bone formation, and no “When a bone is angulated
remodeling.
beyond the limits of bending,
Greenstick Fracture When a bone is angulated beyond the limits of bending,
a greenstick fracture occurs (Fig. 1-4). This is a failure of the tension side of the a greenstick fracture occurs”
bone; the compression side bends. A greenstick fracture occurs when the energy
is sufficient to start a fracture but insufficient to complete it. The remaining
bone undergoes plastic deformation. At the moment of fracture there is consid-
erable displacement—as in most fractures—and then elastic recoil of the soft
tissues improves the position. The fracture can hinge open again subsequently,
owing to muscle pull. Complete closure of the fracture defect, which is pre-
vented by jamming of spicules, can usually only be achieved by completing the
fracture and momentarily overcorrecting the angulation.
Complete Fracture Complete fractures are rarely comminuted in children
(Fig. 1-5). This may be because a child’s bone is more flexible than that of an
adult. Some of the force of impact is dissipated in bending the bone, whereas in
adults the kinetic energy of impact is entirely used to disrupt the intermolecular
bonds in the bone.

Fracture Patterns
The treatment of fractures is helped by an understanding of the differences be-
tween fast and slow fractures, and between spiral and oblique fractures.
The surface of a slow fracture is rough, like a stubbly lawn, whereas a fast
fracture is smooth. Young bone and a rough fracture surface make it easier to
keep the ends hitched.
Spiral Fractures The direction of force decides the direction of the fracture
line (Fig. 1-6). A spiral fracture, produced by a twist, has an intact periosteum
hinge along the straight, axial part of the fracture. If you can find where this is,
you can determine whether the fracture can be reduced by clockwise or coun-
terclockwise rotation and the intact periosteal hinge will help maintain reduc-
tion. These fractures are not held by the three-point pressure principle applica-
ble to transverse fractures and are better held by a “crank-handle” cast (several
right angles), which controls rotation (Fig. 1-7).

Figure 1-3 Traumatic bowing of the ulna in a Figure 1-4 Greenstick fracture in
child. a child. Figure 1-5 Complete fracture in a child.
4 Oblique Fractures An oblique fracture, due to axial overload, usually propa-
Children Are Not Just Small Adults gates at about 30° to the axis of the bone because the periosteum is widely torn;
these fractures are unstable and are best reduced by distraction—a straight pull.
They are held either in traction or by a cast applying potentially risky cir-
cumferential pressure. Longitudinal loading obviously displaces the fracture
(Fig. 1-8).
Transverse Fractures A transverse fracture results from angulation with the
periosteum torn on one side as a fragment of bone buttonholes through. A se-

Figure 1-6 The shape of the fracture tells you Figure 1-7 Spiral fracture.There is an axial pe-
how it was produced. Spiral fractures are shaped riosteal hinge providing longitudinal stability. A
like a pen nib. Oblique fractures are like a ski crank-handle cast prevents displacement.
jump.

John Hunter
1728–1793

Bone Growth—The Role of the Physis

John Hunter of London was the leader of the movement to scientific background, setting the stage for formation of the
place the discipline of surgery in a scientific basis. He helped Royal College of Surgeons. His early animal studies demon-
translate “barber surgeons” into trained surgeons with a strated that longitudinal growth occurs at the physis.
verely displaced transverse fracture is often best reduced by increasing the defor- 5
mity to 90°, so that the end can be unbuttoned; by pulling hard in this 90° an- Physeal Terminology
gulation position; and then (still pulling) by straightening the bone. A three-
point pressure cast will best maintain the reduction (Fig. 1-9).
Butterfly Fractures A butterfly fracture is due to a combination of axial over-
load and angulation (Fig. 1-10). When the fracture is produced by a blow, the
butterfly fragment lies on the side of the bone that was struck. The periosteum
is most damaged on the opposite side, and the fractures are unstable. When the
butterfly fragment is small, three-point pressure may hold the fracture, but usu-
ally distraction is required.

THE PHYSIS
The physis (growth plate), once known as conjugal cartilage (joins or “conju-
gates” adjacent bone) was confirmed to be the center for bone growth by John
Hunter, the renowned British surgical scientist. In the early 1700s while enjoy-
ing a pork dinner with a friend, he noted slightly “colored” transverse lines at
the ends of a young pig’s bone (the pig had been fed garbage contaminated by
madder—a dye for cloth—which was selectively deposited in the growing pig’s
physis).
Suspecting this as the area where bones grow longitudinally, he then con-
ducted experiments, by placing transverse pins in growing animal bones. Those
placed at a certain distance apart in the diaphysis (mid-bone) remained simi-
larly spaced over time. When one pin was placed in the epiphysis and the other
in the diaphysis, the pins separated over time, clarifying that longitudinal
growth came from the physis (growth plate).

PHYSEAL TERMINOLOGY
In describing the physis (growth plate) and adjacent bone, we will use tradi-
tional terminology (Fig. 1-11). Minimal reference to classic language (Greek)
clarifies the terms that center on the physis (growth plate). Growth “plate” de-
scribes the shape of the physeal growth cartilage, in that it is shaped like a small
dish (not very thick, varying diameters). Figure 1-8 An oblique fracture. An
overloaded column fails in this fashion.

Figure 1-9 A transverse fracture. Reduction requires retracing the path of the injury. Figure 1-10 Butterfly fracture. The
It is held by three-point pressure. numbers indicate the order in which the
fractures occur.
6
Children Are Not Just Small Adults
Figure 1-11 The physis (growth plate).
“One still hears the term
‘epiphyseal fracture’ when
the speaker really means
‘physeal fracture’”
Greek Words and a Growing Child’s Bone
“epi - physis” (epiphysis)
epi (Greek) = upon
“upon the physis”
physis (growth plate)
“meta - physis” (metaphysis)
meta (Greek) = beside, next to
“beside or next to the physis”
“dia - physis” (diaphysis)
dia (Greek) = assunder, apart
“apart from the physis – between the physes”
The adjacent bone is named by its association with the physis. The articular
end of the bone is positioned “upon” the physis thus is called the epiphysis
(epi = upon).
Physeal Language Errors
The most difficult remaining descriptive problem relates to the clinical use of
the term epiphysis when one really means physis. One still hears the term “epi-
physeal fracture” when the speaker really means “physeal fracture.” Fractures
can involve the epiphysis, but when they do, there is appropriate language to
describe them. Learning accurate, clear, internationally accepted language for
the description of injuries within and about the physis remains integral to mas-
tering children’s orthopedics.
Physeal Biomechanics
Ruysch (1713) was one of the earliest experimentalists to find that consider-
able force is required to separate the epiphysis from the metaphysis because
they are firmly connected externally by the periosteum and internally by
mamillary processes. In 1820, James Wilson showed that a longitudinal force
of 550 pounds was required to detach the epiphysis from the metaphysis, but
that if the periosteum was divided first the force required was only 119
pounds. A few years later, in 1845, Salmon again demonstrated the impor-
tance of periosteum. Although he could separate the epiphysis of a newborn’s
distal femur by hyperextending the knee, he could not produce displacement
until he cut the periosteum.
In 1898, John Poland wrote Traumatic Separation of the Epiphysis, a book of
900 pages that summarized what was known about the epiphysis to that time.
Since then, very little new information has been added, and those interested in
children’s fractures should read his book. Poland was probably the first to show 7
experimentally that it was easy to produce epiphyseal separation but difficult Physiological Differences
to produce dislocations in children (Fig. 1-12). He wrote, “This is easily un-
derstood when the comparatively weak conjugal neighborhood in the young
subject is realized. The violence producing the two forms of injury—epiphy-
seal separation in children and dislocations in adults—is frequently of the
same character.” (This quotation is better understood if you appreciate that
the growth plate was once called conjugal cartilage, because it joins two bones
intimately together.) Poland concluded that ligaments are stronger than
growth cartilage.
At least one attachment of a ligament is to an epiphysis. Hence, when a val-
gus force is applied to the knee of a child, for example, the distal femoral
growth plate gives way, whereas in an adult the medial ligament will rupture or
detach.
Growth cartilage has the consistency of hard rubber. When the plate is thick,
the epiphysis can be rocked slightly on the metaphysis because of the elasticity
of the plate. This property not only protects the bone from injury but appears
to protect the joint surface from the type of crushing injury that is common in
adults.
In 1950, Harris revived interest in biomechanical testing of the growth plate.
Applying a lateral force to an epiphysis, he found that the hormonal environ- Figure 1-12 Strong ligaments attached
to the epiphysis account for epiphyseal
ment greatly influences the strength of the bond between the epiphysis and the
separation being more frequent than joint
metaphysis. dislocations. Poland was the first to empha-
Bright and Elmore studied the force required to separate the upper tibial epi- size that strong ligaments attached to the
physis in a rat (Fig 1-13) and found that the age of the animal and direction in epiphysis account for epiphyseal separation
which the force is applied are both important factors. The plate is most resistant being more frequent than joint disloca-
to traction and least resistant to torsion. Furthermore, the epiphysis can be dis- tions.
placed 0.5 mm before separation begins. In a subsequent paper, they showed
that small cracks developed within the physis when 50% of the force required
to separate the plate was applied.

PERIOSTEAL BIOMECHANICS
The periosteum is much thicker, stronger, and less readily torn in a child than
in an adult and continuity of the periosteum determines whether or not a frac-
ture displaces. When displacement occurs, the intact hinge of periosteum can
help or hinder reduction.

PHYSIOLOGICAL DIFFERENCES
Growth Remodeling
Growth provides the basis for a greater degree of remodeling than is possible in
an adult. As a bone increases in length and girth, the deformity produced by a
fracture is corrected by asymmetric growth of the physis and the periosteum
(Fig. 1-14). Karaharju and associates studied fractures in puppies’ tibiae that
had been plated with angulation. The physis grew asymmetrically to straighten
up the articular surface. Most of the correction occurred early. Figure 1-13 Load required to separate
the proximal tibial epiphysis of a rat using
Remodeling occurs most efficiently in younger children and if the deformity
forces applied at different angles to the
is in the axis of rotation of the adjacent joint. Thus in a 3-year-old child, a distal growth plate. (Based on Bright RW, Elmore
radius fracture left in bayonet apposition (lateral view) will straighten itself over SM. Physical properties of epiphysieal plate
the next year (Fig. 1-15). cartilage. Surg Forum 19:463, 1968.)
8 The bump of a malunion is corrected by periosteal resorption; the concavity
Children Are Not Just Small Adults
Figure 1-14 The basis of remodeling.
6 Weeks
After Injury 3 Months 1 Year
Figure 1-15 Five-year-old child with a
distal radius fracture that healed in a mal-
reduced position. At 3 months the defor-
mity persists. One year later the radius is
straighter.
.
is filled out by periosteal new bone. This is an example of Wolff ’s law, which
may be mediated by piezoelectric potentials. The compression side of a loaded
bone develops a negative potential, which is a stimulus to bone formation.
Remodeling (perhaps better thought of as realignment), which restores the
function of a bone to normal, must be distinguished from rounding off, which
improves the radiograph but does little for the patient (Fig. 1-16), often leaving
the joint to function at an abnormal angle.
.
.
Overgrowth
A fracture through the shaft of a long bone stimulates longitudinal growth,
probably because of the increased nutrition to growth cartilage produced by the
hyperemia associated with fracture healing. In practice, an undisplaced fracture
of the shaft of the femur will, in the course of a year or two, cause the femur to
be about 1 cm longer than its opposite member. An incomplete, asymmetric
metaphyseal fracture (especially proximal tibia) can cause undesirable progres-
sive angulation over the year following fracture, causing deformity so severe that
on occasion it requires surgical correction.
Progressive Deformity
Permanent damage to the growth plate will produce shortening (Fig. 1-17) or
progressive angular deformity. Such complications have been recognized for
many years, and, in 1888, Lentaigne even diagnosed this condition in an
Egyptian mummy.
Nonunion
Nonunion is an adversary almost unknown to the children’s orthopedic sur-
geon. In fact, when it does occur, especially in the distal tibia, one thinks of as-
sociated disease as the cause (congenital pseudarthrosis due to neurofibromato-
sis). Displaced intra-articular fractures and the rare shaft fracture with gross
interposition may not unite, but otherwise union is easily achieved. As in
adults, femoral neck and scaphoid (carpal navicular) fractures may go on to
nonunion. The reason for ready union in children is not known for certain, but
perhaps the periosteum is actively (not dormantly) osteogenic and clearly chil-
dren have an excellent vascular supply to most fractures.
A Figure 1-16 Remodeling has two
meanings. A) Rounding off does not help
the patient; radiologists call this remodel-
ing to lure the physician into inappropri-
ate optimism. B) Realignment or “straight-
ening itself out” is the real meaning of
B remodeling.
Speed of Healing 9
Physiological Differences
Children heal quickly; therefore reduction should be secured early. The ortho-
pedic surgeon does not have as long to deliberate over a fracture in a child as
compared to an adult.

Refracture
Refracture occurs under several circumstances:
1. Early, when the cast is removed too soon.
2. Late, when the fracture has healed with deformity so that the fracture is a
stress concentrator (Fig. 1-18).
3. Late fracture in cases where the cast was maintained for the advised time
period and the fracture is well aligned.

2 Month Post Injury 3 Years Post Injury Central Physeal Closure

A B C
Figure 1-17 A) Salter-Harris I left distal radius fracture. B) Three years following injury, note radial
physeal closure and ulnar overgrowth. C) MRI confirms physeal arrest.

Initial Injury After “Reduction” 6 Weeks After 1 Month Later Post op

Original Injury

Figure 1.18 Classic example of refracture. This 4-year-old child had a typical fracture that was not very
well reduced. One month after cast removal, a mild fall led to refracture. The patient was taken to the OR
for reduction and fixation.
10 We commonly see the latter in children who pursue vigorous activities (skate
Children Are Not Just Small Adults boarding, motocross, etc., Fig. 1-19).
Studies in rabbit bones show four biomechanical healing stages, each which
can allow refracture:
Stage I: The sticky stage—refracture through the original fracture site
with low stiffness.
Stage II: Early union—refracture through the original site with high stiff-
ness.
Stage III: Refracture occurs partly through the original fracture site and
partly through intact bone.
Stage IV: Refracture entirely through intact bone.

SUMMARY
Children’s fractures differ from similar adult injuries in many ways. The rela-
tively weak physis is prone to injury, and recognition of the many types of phy-
seal injury, with application of modern treatment methods, is central to the art
and practice of children’s fracture treatment. The vigor of growth, with its cor-
responding excellent blood supply to bone, ensures healing in most children’s
fractures. Refracture, thought to be uncommon in the past, is a regular occur-
rence in the modern era that emphasizes “extreme sports.” Overall, the biology
of the child’s musculoskeletal system, blessed with the positive attributes of
Figure 1-19 Refracture is common in
growth, makes treatment a pleasant, positive experience.
children who pursue aggressive sports.
(Photo courtesy of R. Knudson.)

Suggested Readings
Altner PC, Grana L, Gordon M: An experi-
mental study of the significance of mus-
cle tissue interposition on fracture heal-
ing. Clin Orthop 111:269, 1975.
Arunachalarun VSP, Griffiths JC: Fracture
recurrence in children. Injury 7:37, 1975.
Borden S: Traumatic bowing of the forearm
in children. J Bone Joint Surg 56A:611,
1974.
Bright RW, Burstein AH, Elmore SM: Epi-
physeal plate cartilage. A biomechanical
and histological analysis of failure modes.
J Bone Joint Surg 56A:688, 1974.
Currey JD, Butler G: Mechanical properties
of bone tissue in children. J Bone Joint
Surg 57A:810, 1975.
Diab, M: Lexicon of Orthopedic Etymology.
Harwood Academic Publishers. 1999.
Edvardson P, Syversen SM: Overgrowth of
the femur after fractures of the shaft in
childhood. J Bone Joint Surg Br 1976;58:
339-344.
Gordon JE: New Science of Strong Materials
or Why You Don’t Fall Through the
Floor. London, Penguin Books, 1968.
Harris WR: The endocrine basis for slipping
of the upper femoral epiphysis. J Bone
Joint Surg 32B:5, 1950.
Hirsch C, Evans FG: Studies on some physi-
cal properties of infant compact bone.
Acta Orthop Scand 35:300, 1965.
Karaharju EO, Ryoppy SA, Makinen RJ: Re-
modelling by asymmetrical epiphyseal
growth. J Bone Joint Surg 58B:122,
1976.
Mabrey JD, Fitch RD: Plastic deformation
in pediatric fractures: mechanism and
treatment. J Pediatr Orthop 1989;9:310-
314.
Poland J: Traumatic Separation of the Epiphy-
sis. London, Smith, Elder, 1898.
Pritchett JW: Growth plate activity in the
upper extremity. Clin Orthop 1991; 268:
235-242.
Shapiro F, Aoltrop ME, Glimcher MJ: Orga-
nization and cellular biology of the peri-
chondral ossification of Ranvier. A mor-
phological study in rabbits. J Bone Joint
Surg 59A:703, 1977.
Treharne RW: Review of Wolff ’s law and its
proposed means of operation. Orthop
Review 10:35, 1981.
Tschantz P, Taillard W, Ditesheim PJ: Epi-
physeal tilt produced by experimental
overload. Clin Orthop 123:271, 1977.
White AA, Punjabi MM, Southwick WO:
The four biomechanical states of fracture
repair. J Bone Joint Surg 59A:188, 1977.
Wolff J: The classic: concerning the interrela-
tionship between form and function of
the individual parts of the organism. Clin
Orthop 1988;228:2-11.
 The Physis and
2
Skeletal Injury
Mercer Rang m Dennis Wenger

• Epiphyseal Fractures 11
• Physeal (Growth Plate) Injuries 12
• Healing Reactions of the Physis and
Epiphysis 14
• Salter-Harris Classification 16
• Guide to Care of Physeal Injuries 21

INTRODUCTION
Many fractures in children would heal well, whether they were looked after by a
“The physis alone
professor in a university hospital or by Robinson Crusoe on a deserted island. accounts for much
Fractures through the physis (growth plate) are a different story.
of why children’s
EPIPHYSEAL FRACTURES
orthopedics has
Fractures of the true epiphysis usually involve the growth plate but occasionally
occur in isolation. They may be classified as follows (Fig. 2-1): become a sub-
! Avulsion at the site of ligamentous attachment specialty”
! Comminuted compression fracture .

! Displaced osteochondral fragment — ANONYMOUS

11
12
The Physis and Skeletal Injury
Figure 2-2 Anterior tibial spine fracture
in a child who had a bicycle accident.
Figure 2-3 Osteochondral fracture of
the lateral femoral condyle secondary to
acute traumatic patellar dislocation. The
fragment was large enough that it could be
surgically repositioned.
Figure 2-1 Epiphyseal fractures not involving the growth plate.
Avulsion at the Site of Ligamentous Attachment
The common sites of this injury are the tibial spine (Fig. 2-2), the ulnar styloid,
and the base of phalanges. The bony fragment retains an adequate blood supply
and does not undergo avascular necrosis. If the fragment is displaced, union is
rare because synovial fluid inhibits callus formation. The displaced fragment
may block joint movement or may leave the joint unstable because of func-
tional ligamentous lengthening. These problems justify accurate reduction:
sometimes requiring open reduction.
Osteochondral Fragments
Osteochondral fragments are most commonly scalped off the distal femur, the
patella, the capitellum (humerus), and the radial head. A displaced fragment
produces the problems of a loose body and articular cartilage injury. If the frag-
ment is large and from an important part of the joint, it should be replaced and
fixed anatomically (Fig. 2-3). If small, it should be removed. Often, the frag-
ment has little bone attached and is difficult to see on x-ray (especially radial
head and capitellum).
PHYSEAL (GROWTH PLATE) INJURIES
Injuries to the growth plate form perhaps one third of skeletal trauma in chil-
dren. The possible consequences of such injuries include progressive angular de-
formity, progressive limb-length discrepancy, and joint incongruity. Although
damage to the growth plate has the potential for causing many disastrous prob-
lems, in fact, the area repairs well, and problems after injury are uncommon
when treated well. When growth is disturbed, the reason is one of the following:
! Avascular necrosis of the physis
! Crushing or infection of the physis
! Formation of a bone bridge between the bony epiphysis and the metaphysis
! Hyperemia producing local overgrowth
The problems and the means of their prevention can only be understood by an
appreciation of the anatomy and the healing reactions in the growth plate area.
Anatomy 13
Physeal (Growth Plate) Injuries
The growth plate is a cartilaginous disc situated between the epiphysis and the
metaphysis. The germinal cells are attached to the epiphysis and have a blood
supply from epiphyseal vessels (Fig 2-4). Repeated multiplication of these cells
provides the cell population for the rest of the plate. The daughter cells multiply
further, secreting a cartilage matrix, and increase in size, thereby producing
growth. The matrix calcifies. Metaphyseal vessels enter the cell columns, remove
a little matrix, and lay down bone on the cartilage matrix to form metaphyseal
bone.
With a fracture, the plane
. of separation is most frequently the junction be-
. tween calcified and uncalcified cartilage. A transverse section through the

growth plate in this region demonstrates the small amount of structural matrix
present, which probably accounts for the relative weakness of the area. The im-
portant germinal part of the plate—indeed the greater thickness of the plate—
remains mostly with the epiphysis. This plane of separation is relatively blood-
less, so that an epiphyseal separation often has little associated swelling.
However, when the plane of fracture separation has been examined carefully,
the anatomic fracture line is often less “pure.” It has been noticed that it may
pass between the epiphysis and the germinal layer. Johnston and Jones per- Figure 2-4 Blood supply of the growth
formed biopsies of fractures requiring open reduction and found that the frac- plate. Damage to the epiphyseal artery can
ture line often passes between the epiphysis and the germinal layer. destroy the plate. Damage to the metaphy-
seal artery is less important.
This is particularly the case in fractures through the physes that have signifi- .
cant natural undulations (a “hilly terrain”) such as the distal femur and distal
tibia (Fig. 2-5). These undulations may be evolutionary design features that
prevent easy disruption of the physis but when it finally is forced to give, the
shearing action may predispose to a fracture. If reduction is not anatomic, there
will be epiphyseal-to-metaphyseal bone contact, which may form a bar across
the physis. Obviously, if much of the germinal layer is disturbed, there is a
chance for growth arrest.

Blood Supply to the Epiphysis

The blood supply of the epiphysis is important. Dale and Harris showed that
there are two fundamental types of epiphyses (Fig. 2-6) according to how they
receive their blood supply. The prognosis after physeal injury is greatly deter-
mined by this factor.

Figure 2-5 The irregularity and undula-
tions in certain physes may increase the
risk for physeal closure with fracture (e.g.,
“Kump’s bump”—distal tibial physis).
A B
Figure 2-6 The blood supply of two types of epiphyses. A) Vessels to the femoral head
track in the periosteum under the synovium.A periosteal tear or a high-pressure effusion may
cause AVN. B) Vessels to the distal femur pass through a thick wad of soft tissues and are
rarely disrupted with a fracture.
14 At Injury
The Physis and Skeletal Injury

After Fixation

AVN
—Femoral Head

Figure 2-7 This 12-year-old boy fractured his

greater trochanter in a football injury. Although
promptly and anatomically reduced, he developed
AVN of the femoral head due to disruption of the
vessels that ascend the femoral neck.

Epiphyses Totally Clad with Cartilage (such as head of femur, head of ra-
.
dius). Total interruption of the blood supply to the germinal cells may follow
fracture separation. Avascular necrosis of the plate and epiphysis, and arrest of
longitudinal growth naturally follow (Fig. 2-7).
Epiphyses with Soft Tissue Attachments (most physeal injuries—distal
radius, distal tibia, distal femur, etc.). When these are separated, the soft tissue
hinge will remain attached to the epiphysis, so that the circulation to the epiph-
ysis remains intact. The germinal cells are not injured, and longitudinal growth
continues unscathed.

HEALING REACTIONS OF THE PHYSIS

AND EPIPHYSIS
Dale and Harris have published the most credible description of growth plate
separation. The plate separates mostly between the calcified and uncalcified lay-
ers of the growth plate. For a week or two, the hiatus is filled by fibrin. Initially,

Figure 2-8 Healing after growth

plate separation occurs by means of
new bone formed by the growth plate
and by the periosteum. This can be
seen clearly 3 weeks after the initial
injury.
 15
Healing Reaction of the
Physis and Epiphysis

Figure 2-9 Healing patterns of Type IV injuries.

the physis becomes wider, because growth cartilage continues to be produced

without invasion by metaphyseal vessels. After about 2 weeks, the vessels begin
to invade the cartilage columns again. The physis becomes narrower once more,
and the healing occurs without leaving a scar. In this way, the growth plate heals
more quickly than a fracture through bone (Fig. 2-8). The repair of an injury at
right angles to the plane of the growth plate shows more variation (Fig. 2-9).
Cartilaginous Epiphysis If they remain displaced, both portions of the epiph-
ysis continue to grow separately, producing a double-ended bone.
Ossified Epiphysis If the fracture surfaces are not in contact, both fragments
continue to grow for some time. Eventually, premature arrest of growth adja-
cent to the fracture line takes place.
If the fracture surfaces are approximated but without anatomic reduction of
the growth plate, a bridge of callus will form between the epiphysis on one side
and the metaphysis on the other. This bony bridge produces a brake on
growth. When the bridge is at the center of the epiphysis, the two outside
edges will continue to grow, resulting in tenting of the end of the bone. When
the bridge is toward one margin of the growth plate, a progressive, angular de-
formity develops.
If the fracture is accurately reduced so that there is coaptation of the growth
plate, there will be a small scar at the site of growth plate injury, but this is not
sufficient to disturb growth.
16
The Physis and Skeletal Injury
Hugh Owen Just Lucas-
Thomas Championniere
England France
1834-1891 1843-1913
Prolonged Immobilization
or Early Motion?
The controversy regarding whether
fractures should be casted for a long
time or removed early were champi-
oned by the above experts.Thomas be-
lieved that fracture immobilization
should be enforced, prolonged, and un-
interrupted to ensure fracture healing.
Lucas-Championniere vigorously op-
posed principles of treatment of frac-
tures by prolonged rest. He advocated
early motion and is considered one of
the founding fathers of modern fracture
brace treatment that allows early mobi-
lization of joints.A-O principles and
Salter’s CPM ideas follow this concept.
¥¥¥¥Me÷
Table 2–1 Salter-Harris Classification
S.H. I
Fracture through physis Fracture through physis
extending through meta-
physis (with resulting tri-
angular Thurston-Holland
fragment)
. Fhurston
Effect of Internal Fixation Small Kirschner wires passed through the center of
the plate do not interfere with growth. If they are passed near the margin of the
plate, growth is occasionally disturbed. Threaded pins or screws across the plate
act as effectively as Blount’s staples in inhibiting growth.
Repair of Articular Surfaces Cartilage defects in a joint invite intra-articular
adhesions. Salter and associates have shown that continuous passive motion
(CPM) not only discourages adhesions but stimulates more rapid and complete
healing of full-thickness defects in rabbits. Motion—not immobilization—for
injured joint surfaces would seem wise; however, often early motion will in-
crease the chance for pseudarthrosis. Finding the happy medium is the art.
CPM is rarely required following primary treatment of children’s joint fractures
(as opposed to adults who are much more likely to become stiff ).
SALTER-HARRIS CLASSIFICATION
The Salter-Harris classification of growth plate injuries remains the most practi-
cal and commonly used. Founded on the pathology of injury, the classification
is well suited to an accurate verbal description of a fracture and provides an ex-
cellent guide to rational treatment (Table 2-1). Most growth plate injuries can
be easily classified, leaving very few fractures. to produce arguments at fracture
rounds. The classification should be studied in the original, as it is one of the
classic papers in orthopedics.
There have been others. In 1898, Poland illustrated the common variations
of separation (Fig. 2-10). The Weber classification (from the A-O) provides the
extreme of simplicity (Fig. 2-11). In very general terms, a Weber Type A (equiv-
alent to Salter-Harris I or II) can be treated conservatively, and a Type B (equiv-
alent to Salter-Harris III or IV) requires surgery.
The antithesis of the Weber classification is that of Ogden who proposed
nine types of physeal injuries (including intra-articular fractures, osteochondral
avulsions, etc.). His system may be useful for research studies but has proven to
be too complex for easy memorization (and thus everyday clinical use). Most
classification systems in medicine that have more than three or four subgroups
cannot be readily memorized, and used on a day-to-day basis.
S.H. II S.H. III S.H. IV S.H.V
.
Fracture through physis Fracture through epiph- Compression fracture
extending through ysis and metaphysis through physis not
epiphysis crossing the physis extending to epiphysis
or metaphysis
Holland Fragment Continues togww )
-
 17
Salter-Harris Classification

Robert Salter Robert Harris

Salter and Harris, both internationally recognized orthopedic surgeons
from the University of Toronto, published a classification of growth plate
fractures in 1963 that remains the most commonly used worldwide.

Only simple, practical classifications gain wide acceptance (and get dictated Figure 2-10 Poland’s classification of
growth plate injuries (1898).
into medical records and correspondence). Thus the classic Salter-Harris classi-
fication system remains the most commonly used worldwide.

Fracture Types (Salter-Harris)

Type I In a Type I fracture (Fig. 2-12), the epiphysis separates completely
from the metaphysis. The germinal cells (the growth cells) remain with the
epiphysis, and the calcified layer remains with the metaphysis. If the periosteum
is not completely torn, there may be little or no displacement. The radiograph
in these circumstances may be normal and the diagnosis is made on clinical
suspicion (Fig. 2-13).

B
Figure 2-11 This extremely simple
classification was described by Weber and
Brunner in St. Gallen, Switzerland. Type
A can be treated with closed reduction.
Type B requires surgery (in most cases). Figure 2-12 Type I fracture, the epiphysis separates completely from the metaphysis.
18 Most parents look on these injuries as sprains, because there often is little
The Physis and Skeletal Injury swelling and little deformity. You will be alerted to them by tenderness over the
growth plate and should not be disturbed by the absence of radiologic signs.
Stress radiographs may be taken if accurate diagnosis is imperative but are rarely
performed in the modern era (pain issues, how much stress?, what is learned?).
Diagnosis of separation of an unossified epiphysis in a very young child is more
difficult and is made on clinical signs, the presence of soft tissue swelling, or
possible swelling noted on an x-ray or with ultrasound.
Type I injuries are usually the result of a shearing, torsion, or avulsion force.
Apophyses can also be separated with a Type I pattern (base of fifth metatarsal,
medial epicondyle) with an avulsion force the likely mechanism. Pathologic
Type I injuries occur in scurvy, rickets, disorders associated with hormonal im-
balance, and osteomyelitis (Fig. 2-14).
When the periosteum is torn, displacement is easily reduced without any sat-
isfying crepitus and often with little sensation that the fragment is snapping
back into position, because the two fracture surfaces are covered with cartilage.
Early healing occurs within 3 weeks, and problems are rare. Exceptions in-
clude a displaced fracture of the proximal femoral physis with subsequent avas-
cular necrosis, which has a grim prognosis. Nonunion of a separated medial epi-
condyle is not uncommon and may cause subsequent instability.
It is often difficult to distinguish between a Type I injury of the growth plate
(which has an excellent prognosis) and a Type V injury (in which the plate is
crushed) which has a poor prognosis. The history of injury is the best guide
with Type V injuries produced by axial compression. These injuries will need to
be followed more closely regarding subsequent physeal closure.
Type II The cleavage plane of a Type II injury (Fig. 2-15) passes through
much of the plate before the fracture angles through the metaphysis. The frac-
ture is produced by lateral displacement force, which tears the periosteum on
one side but leaves it intact in the region of the triangular metaphyseal frag-
ment, known as the Thurston-Holland fragment after the radiologist who first
described it.
The fracture is easily reduced, and overreduction is prevented by the intact
periosteum. The cartilage-covered surfaces usually prevent the sensation of

Figure 2-14 Separation of both distal femoral

Figure 2-13 Typical Salter-Harris I fracture of the distal fibula. The
x-rays appear normal but the patient has focal tenderness over the
physis (not over adjacent ligaments) confirming the diagnosis.
epiphyses. For 6 weeks this boy, aged 3 years, had
been treated with antibiotics and steroids for
fever and multiple joint pain. By the time a diagno-
sis of osteomyelitis was reached, the epiphyses
had separated.
 19
Salter-Harris Classification

Figure 2-15 Classic Salter-Harris II fracture of the distal femur with a triangular Thurston-
Holland sign (outlined). Even with anatomic reduction, nearly 40% of distal femoral physeal
fractures will have subsequent physeal closure.

crepitus as the fragment is pushed into position. When the radial head is sepa-
rated, for example, it may be impossible to judge the success of a reduction by
clinical means.
Figure 2-16 Classic Type III fracture of
Occasionally, the shaft of a bone will become trapped in the buttonhole tear
medial malleolus in a child.
of the periosteum. This is most common at the shoulder if there is a large,
metaphyseal fragment poking through a small periosteal tear. If the degree of
displacement is unacceptable, open reduction is sometimes required. Also, dis-
tal femoral fractures may require open reduction plus K-wire fixation (and have
a high risk for physeal closure).
Type III Type III injuries are most commonly seen in partially closed growth
plates such as the distal tibia. The plane of separation passes along with the
growth plate for a variable period before entering the joint through a fracture of
the epiphysis. The fracture is intra-articular and requires accurate reduction to
prevent malarticulation.
Open reduction is often required, but the fragment should not be dissected
free of its blood supply. The most common site is at the distal end of the tibia,
toward the end of growth, when the medial half of the plate is closed (Tillaux
fracture). Growth disturbances, therefore, are not a problem. Another common
site is the medial malleolus; however, often a tiny Thurston-Holland fragment
remains attached, making a Type III versus Type IV call difficult (Fig. 2-16).
Type IV The fracture line in a Type IV injury passes from the joint surface,
across the growth plate, and into the metaphysis (Fig. 2-17). The most common
example is a fracture of the lateral condyle of the humerus; medial distal tibial frac-
tures (medial malleolus) are also common (but as just noted, this can be a Type
III).
This is an injury for which a surgeon can do a great deal. Left alone, this in-
jury will produce joint stiffness and deformity owing to loss of position,
nonunion, and growth disturbance. The fracture must be accurately reduced,
usually by open reduction and internal fixation, both to secure a smooth joint
surface and to close the fracture gap. This allows cell-to-cell apposition of the Figure 2-17 Classic Salter-Harris IV
growth plate and ensures that growth is not disturbed as well as minimizes the fracture of the lateral condyle of the distal
risk for nonunion. humerus requiring open reduction.
20
The Physis and Skeletal Injury
Figure 2-19 One of the earliest radi-
ographs of a Type V injury was published by
Poland in 1898. The growth plate of the ra-
dius has closed, and the radius has not
grown. Note ulnar overgrowth.
At Injury
Figure 2-20 This 8-year-old girl fell from a balcony and was thought to have a simple right midshaft
femoral fracture and was treated with a spica cast.Three years later, her right femur was found to be short
due to occult distal femoral physeal closure. Hresko et al. and Bowler et al. have described this phenomenon
(see Suggested Readings).
A B C
Figure 2-18 Not all Type IV injuries are the same. A) When the fracture line crosses a
bony epiphysis, the risk of bony callus bridging the growth plate and causing a growth distur-
bance is great if accurate reduction is not achieved. B) When the fracture line passes through
a cartilaginous epiphysis, bridging is less likely. C) A stepped fracture line sometimes allows a
stable closed reduction.
At other sites, the growth plate cannot be seen clearly, and when there is
doubt about whether it is accurately reduced, some have suggested that the sur-
geon should improve the view by removing the metaphyseal fragment (medial
distal tibia). The gap can be filled with fat to discourage bridging. There are sev-
eral subvarieties of this injury that are not generally known (Fig. 2-18).
Type V Concepts about Type V injuries are changing (Fig. 2-19). In the origi-
nal concept, the plate is crushed, thereby extinguishing further growth. All or
part of the plate may be affected. A compression injury of the plate may seem
like nothing more than a sprain at first, and only later will the true nature of the
lesion be recognized.
At other times, a Type I or Type II injury is obvious initially; then pressure
from the most prominent corner of the metaphysis produces a crushing injury,
to the chagrin of the surgeon and to the detriment of the patient. Also, a Type
V injury can occur in an occult manner. In association with a long bone frac-
ture (Fig. 2-20) patients with severe injury mechanisms should often be fol-
lowed for at least a year to be sure that physeal closure has not occurred. In the
case of an occult closure, the clinical exam may be more important (limb-length
change, angular deformity) than the x-ray which will be initially directed at the
injury site (midshaft femur) rather than the physis.
Since the work of Langenskiold, Bright, and Peterson on growth arrest
owing to bony bridging, the classical concept of a Type V injury needs reexam-
After Healing Late Physeal Closure
ining. When a small area of the growth plate is damaged, there is a race to re- 21
place the defect. Either regenerated growth cartilage or bone may win. Growth Guide to the Care of Physeal Injuries
is threatened if bone forms. The surgeon’s focus should be on the bridge rather
than the crush, if only because the bridge can be treated.
All significant growth plate injuries should be followed for at least 6 months
and perhaps a year because growth disturbance is a possibility. The cost for fol-
low-up examination and x-rays as well as the added x-ray exposure make “All significant growth plate
mandatory follow-up less critical in mild injuries (Type I, Type II in younger injuries should be followed
children with mild fracture mechanisms). Again, the art of practice is required.
In such cases, we state that “Physeal closure is possible but very unlikely. If
for at least 6 months and
your limb seems to be getting shorter or appears to angulate over time, see your perhaps a year because
family doctor for confirmation and referral to orthopedics.” PRN returns are growth disturbance is a
often unwise in dictations; instead tell the patient, “If you detect or suspect any
problem, please return to see me” and dictate “The patient is encouraged to re- possibility”
turn if either the patient or the family doctor note any abnormalities.”
Type VI A scalping injury to the edge of the physis produces a perichondral
ring injury, removing both the edge of the physis and associated perichondral
ring of Ranvier (Fig. 2-21). Injuries of the medial malleolus, from lawn mower
injuries, are the most common cause in the midwestern part of the United States
(where children help their parents with lawn mowing chores—or at least share
the ride). Such lawn mowing injuries are much less common in the southwestern
United States where hired adults (gardeners) operate most lawn mowers.
Often, there is associated skin loss and the avulsed bone fragment is not re-
coverable (ground to bits at the scene of the accident). These injuries are diffi-
cult to treat and almost routinely lead to physeal closure. Plastic surgery assis-
tance may be needed to get skin coverage and subsequent operations may be
needed to deal with physeal closure.
The perichondrial ring may also be lifted from the distal femoral condyle by
the lateral collateral ligament, and this too carries the risk of bridging unless it’s
accurately replaced. A progressive varus deformity follows because bone replaces
the perichondrium.

Stress Injuries of the Growth Plate

The concept of stress fracture through the growth plate was introduced by God-
shall and others. It is a natural development, from the observation by Bright
and associates, that shear cracks in the growth plate are seen when the load ap-
plied to the plate is 50% of that necessary to separate the plate. Continued in-
jury could be expected to inhibit healing. Godshall and associates described
pain in the knee, inability to run, and circumferential tenderness around the
distal femoral growth plate. X-ray films showed widening of the growth plate.
After 12 weeks of rest, the lesion healed. These lesions are seen in gymnasts (dis-
tal radius) and baseball pitchers (proximal humerus, elbow) (Fig. 2-22). Os-
good-Schlatter disease offers a further example.

GUIDE TO THE CARE OF

PHYSEAL INJURIES
Defining the Exact Line of the Fracture
This is usually obvious, but some injuries can be very difficult, particularly in Figure 2-21 Diagram of scalping injury
the young child with little or no ossification in the epiphysis. Multiple views, (Type VI) of medial malleolus as might be
with comparative views of the opposite side, may help. (An orthopedist should seen with a lawn mower injury.
22
The Physis and Skeletal Injury
Figure 2-23 Before you go to surgery
with a puzzling physeal fracture that you
do not understand, you should consult a
wise senior colleague (Dr. Sutherland, San
Diego, and the late Dr. Heinz Wagner,
Nuremburg).
Wide Physis Normal Shoulder
Figure 2-22 X-rays of a 12-year-old male baseball pitcher who tried to pitch every day. He
presented with right shoulder pain. The physis shows widening (really thickening) due to
chronic repetitive stress.
selfishly think that humans are made symmetrical for the purpose of radi-
ographic comparison.) Stress films are occasionally considered and arthrogra-
phy may be helpful.
CT scans and particularly MRI studies have greatly improved our diagnostic
capacity. The demanding parent, who insists on an MRI study (sometimes an-
noyingly), may be on track in this instance. Occasionally, even after an arthro-
gram or MRI you will remain puzzled and still suspect a displaced intra-articu-
lar fracture but cannot prove it. In such cases, it is usually wiser to err in favor of
exploration than to rely on your small stock of undeserved miracles.
Consulting Senior Colleagues
When in doubt, discuss the case with a radiologist and consult a senior col-
league (Fig. 2-23). One should not finalize a treatment plan until the diagnosis
is clear. As noted previously, it is usually better to explore a puzzling physeal in-
jury (open surgery) rather than cast, with hope that all will “turn out well.”
Other Issues
Reduction should be early and gentle. These injuries unite quickly, so that at-
tempts to correct malposition after 7-10 days are liable to do more damage than
good to the physis. Repeated efforts at reduction may do nothing more than
grate the plate away. If long-term problems are anticipated, whenever possible
they should be communicated to the parents (without unduly alarming them)
preoperatively.
Open or Closed Reduction?
It is usually possible to secure closed reduction of Type I and Type II injuries.
Exact anatomic reduction, although desirable, may be unnecessary, because re-
modeling can correct many imperfections. Occasionally, soft tissue is interposed
(e.g., at the ankle) or the part is so deeply placed (e.g., the radial head) that
open reduction will be needed.
Open reduction is also required for significantly displaced separations of the
medial epicondyle. Stability is sometimes achieved with a few periosteal sutures
or more commonly a screw. Type III injuries commonly need open reduction in
order to secure a smooth joint surface. Type IV injuries are commonly unstable,
and accurate reduction is mandatory, both to ensure an anatomic joint and to
ensure subsequent normal physeal growth.
This applies particularly to the lateral condyle of the humerus; it may be pos-
sible to reduce this injury, but it is difficult to be sure that it is stable and almost
impossible to be sure (by examining radiographs of a flexed elbow taken
through a cast) that the position is maintained. For these reasons, open reduc- 23
tion and internal fixation are much safer. Guide to the Care of Physeal Injuries

Infection—Chondrolysis
A growth plate may be destroyed by infection. This is a risk in all open fractures
and to a lesser extent in any fracture in which open reduction is carried out.
Kirschner wires used to maintain reduction often traverse joints and can lead to
joint sepsis and chondrolysis as well as osteomyelitis (Fig. 2-24). For this reason,
all K-wires should be either buried below the skin or removed early to minimize
the risk.

Length of Immobilization
Various rules are invoked. The elbow may become stiff if immobilized for more
than 3 to 4 weeks. For other joints, we allow 4 weeks for early union of an epi-
physeal separation, and 6 weeks in a metaphyseal or diaphyseal fracture. Note
the term “early union.” The cast is removed well before solid structural union
has occurred and the family must know this.
The child’s activity level and temperament may require variations in advice
[longer immobilization for dynamic athletes, attention deficit disorder (ADD) pa-
tients, and when parental control is an issue]. Children rarely get stiff joints, even if
the cast immobilization extends a few weeks beyond what is usually advised. When
the cast is removed, the fracture is only partially healed and patients must be ad-
vised of this (“healing”—not “healed”). Post-case splinting may decrease the
chance for refracture in the dynamic child (most children fit this category).

Patient from “Elsewhere General Hospital”—

Late Diagnosed Cases
Children presenting late with Type I and Type II injuries more than 7-10 days
old, even though not adequately reduced, should be left with the displacement
uncorrected, for fear of damaging the growth plate. Corrective osteotomy can
be performed later if remodeling fails.
Open reduction of displaced Type III and Type IV injuries may be better un-
dertaken late than never. Be careful not to devascularize the fragment at the
time of replacement.

A B C
Figure 2-24 A) This child had a lateral condyle fracture with attempted K-wire reduction. B) The tech-
nique was suboptimal with the pins crossing at the fracture site. The child was very active and the frag-
ment rotated on the cross pins. C) The films show malunion of the condyle, as well as probable AVN.
24
The Physis and Skeletal Injury
Figure 2-25 Plane films and CT study
(lateral view) of a distal radius physeal bar
(that followed a Salter-Harris II fracture).
2 Month Post Injury
A B
Figure 2-26 A) Salter-Harris I distal radius fracture. B) Three years following injury, note ra-
dial physeal closure and ulnar overgrowth. C) MRI confirms physeal arrest.
Bony Bridging (Physeal Closure Due to Trauma)
Growth stops when a significant bony bridge joins the epiphysis to the metaph-
ysis. (note that a very small bridge can form and then be “broken” by the dis-
tractive power of a growing physis.) An early sign of a bony bridge may be a
converging Harris line. In the early stage, the patient is free of deformity and
complaints. In most patients, it takes many months to be sure that the bridge is
real. Declaring physeal closure either too early or too late is inappropriate. A
CT or MRI should be taken to confirm the diagnosis and to define the size of
the bridge (Fig. 2-25).
Since Langenskiold, Bright, and Peterson described operative intervention
that can allow resumption of growth after resection of the bridge, there has
been much more reason to follow growth plate injuries carefully. Langenskiold
replaced the bridge with autogenous fat, Bright with silicone rubber, and
Peterson with methyl methacrylate. Silicon is no longer available, thus fat or
methacrylate remain as the best choices. Careful delineation of the bridge size is
made using a CT or MRI methods. The bridge is approached by making a win-
dow in the metaphysis.
Loops and a headlamp improve vision. The bridge is pale bone, in contrast
to the red bone of the normal metaphysis. The bridge is removed with a curet
or burr until the normal plate is seen. The bridge is usually more extensive than
expected (Fig. 2-26). Image views during surgery may help to localize the
bridge so that not too much and not too little is removed. The defect is then re-
placed with fat or methyl methacrylate.
Langenskiold reviewed 33 cases in 1978 with excellent results. A second op-
eration for recurrence was indicated in three patients. Deformity has improved
in most, but some have required osteotomy. Peterson has also reported promis-
ing results. Our experience suggests that his operation has only a 30%–50%
chance for success. The surgery is technically demanding and surgeon experi-
ence benefits the patient. Even referral centers, with multiple orthopedic staff,
should have one surgeon do all of these cases (so that the benefit of experience
can be accumulated).
Central Physeal Closure
3 Years Post
Injury
.
C
SUMMARY—PHYSEAL INJURY 25
Suggested Readings
Fortunately, the majority of growth plate injuries involve little risk of growth
disturbance. In a few, simple surgical intervention can make a great deal of dif-
ference to the outcome of the injury. Happily, the number of children who have
irretrievable damage is very small.

Suggested Readings
Bright RW: Operative correction of partial
epiphyseal plate closure by osseous-bridge
resection and silicone-rubber implant. J
Bone Joint Surg 56A:655, 1974.
Bright RW, Burstein AH, Elmore SM: Epi-
physeal-plate cartilage. A biomechanical
and histological analysis of failure modes.
J Bone Joint Surg 56A:688, 1974.
Bowler J, Mubarak S, Wenger D: The tibial
physeal closure and genu recurvatum
after femoral fracture. J Pedatr Orthop
10:653, 1990.
Brunner CH: Fracture in and around the
knee joint. In Weber BG, Brunner C,
Freuler F (eds): Treatment of Fractures in
Children and Adolescents: New York,
Springer-Verlag, 1979.
Carlson WO, Wenger DR: A mapping
method to prepare for surgical excision of
a partial physeal arrest. J Pediatr Orthop
4:232-238, 1984.
Dale GC, Harris WR: Prognosis in epiphy-
seal separation. An experimental study. J
Bone Joint Surg 40B:115, 1958.
Godshall RW, Hansen CA, Rising DC:
Stress fractures through the distal femoral
epiphysis in athletes. Am J Sports Med
9:114, 1981.
Hresko M, Kasser J: Physeal arrest about the
knee associated with non-physeal frac-
tures in the lower extremity. J Bone Joint
Surg (Am) 71:698 1989.
Johnston RM, Jones WW: Fractures through
human growth plates. Orthopedic Trans-
actions 4:295, 1980.
Langenskiold A: Surgical treatment of partial
closure of the growth plate. J Pediatr Or-
thop 1:3, 1981.
Ogden JA: Skeletal injury in the child.
Philadelphia: Lea and Febiger, 3rd Ed.
2000.
Peterson HA: Operative correction of post-
fracture arrest of the epiphyseal plate: case
report with ten-year follow-up. J Bone
Joint Surg Am 1980;62:1018-1020.
Peterson HA: Partial growth plate arrest and
its treatment. J Pediatr Orhtop 1984;4:
246-258.
Rigal WM: Diaphyseal aclasis. In Rang M
(ed): The Growth Plate and its disorders.
Baltimore, Williams and Wilkins, 1969.
Salter RB, Harris WR: Injuries involving the
epiphyseal plate. J Bone Joint Surg
45A:587, 1963.
Salter RB, Simmonds DF, Malcolm BW et
al: The biological effect of continuous
passive movement on the healing of full-
thickness defects on articular cartilage. J
Bone Joint Surg 62A:1232, 1980.
 Orthopedic Literacy:
3
Fracture Description and
Resource Utilization
Dennis Wenger

• Introduction—Terminology 27
• Fracture Language 28
• Language and Families 34
• Resource Utilization—What Requires
Emergency Reduction? 36
• Educating Families Regarding Urgency 38

INTRODUCTION—TERMINOLOGY
Fracture language, which has evolved in a relatively standard manner through-
“In a work of art
out the world, makes medical communication more efficient. Learning fracture
language, like learning a foreign language, requires time and exposure. In this
the intellect asks
chapter we will present common orthopedic terminology concepts that facili- the questions; it
tate orthopedic communication and care.
does not answer
Descriptive Planes them”
Describing fractures depends on first understanding the accepted terms used to
describe the human body in three dimensions. The coronal plane (frontal plane) —HERBEL
is at right angles to the sagittal plane, dividing a structure into anterior and pos-
27
28
Orthopedic Literacy: Fracture
Description and Resource Utilization
terior portions. The sagittal plane is a pure lateral view. The axial (transverse)
plane is a cross section, as one might see on a CT or MRI study of the spine.
Also, orthopedic terminology is generally described as if one were visualizing
a standing human with the upper extremities in extension and externally ro-
tated (forearm supinated), thus the confusion in describing forearm and hand
anatomy. With the forearm pronated, one would think of the thumb as being a
medial structure yet by anatomic standard (forearm supinated) it is lateral. Thus
the terms “radial” and “ulnar side” are best used for localizing forearm and hand
conditions.

“Learning fracture language, FRACTURE LANGUAGE

like learning a foreign Beginning orthopedic residents rapidly adopt the “tools of their trade,” which
language, requires time and include development of an “orthopedic language” as one of the most critical
learned skills, both for the spoken and written word (letters, reports). Direction
exposure” of displacement is commonly used to describe joint dislocation with wide ac-
ceptance that when one describes a posterior dislocation of the knee that one
means the more distal member (tibia) is posteriorly positioned in its relation-
ship to the femur.
The efficiency of “varus” and “valgus” rather than a full descriptive sentence
quickly becomes apparent. Rather than stating that “the ankle fracture has
Common Greek & healed in slight angulation with the heel in a more lateral position than would
Latin Terms used in be normally expected” we simply state “the ankle is in valgus.” What a triumph
Orthopedics of efficiency! Once this “lingua franca” has been mastered, life becomes easy for
the doctor but frustrating for patients, especially if their doctor does not under-
Cubitus = Elbow
stand the necessity of reverting to common language when speaking to children
Coxa = Hip and their families.
Genu = Knee
Hallux = Great toe
The Forearm—Pronation and Supination
Pes = Foot
Pronation (from Latin pronus): Turned or inclined forward.
Carpus = Wrist
The Roman scholar and husbandman M.T. Varro (116-27 B.C.) defined the prone
Tarsus = Ankle position as lying on the belly with the hands above the head, such that the back
projects away from the palms and the palms project toward the ground.
Pronation = Forearm turned
inward Supination (from Latin supinus): Turned or thrown backward, opposite of Latin
pronus.
Supination = Forearm turned
outward From Diab M. Lexicon of orthopaedic etymology, 1999

“Rather than stating that ‘the fracture has

Left
healed in slight angulation with the heel
in a more lateral position than would be
normally expected’ we simply state ‘the
ankle is in valgus’”
X-ray
viewed
from
behind

Valgus position – left ankle

 Standard Positions and Planes

Sagittal Plane Coronal (Frontal) Plane Axial (Transverse) Plane

The anatomic position

—most descriptions apply to this
standardized position.

29
30
Orthopedic Literacy: Fracture
Description and Resource Utilization
Figure 3-1. Cubitus varus, right elbow fol-
lowing a right supracondylar humerus frac-
ture.
Figure 3-2. Coxa vara of the right hip of
uncertain etiology (old fracture versus
congenital coxa vara).
Learning Varus and Valgus
“The ‘R’ and ‘L’ School of Thought”
This simple method works well for many.
vaRus—focus on the R, R = round like a circle
vaLgus—focus on the L,A valgus deformity (in a severe form)
looks like the letter L
vaRus vaLgus
Frontal Plane Descriptions (Coronal)
The terms varus and valgus, easily learned on externally evident joints (knee,
ankle), require a bit of experience to be used for the elbow and hip. None of the
many memory assisting methods speed the process very much. Salter empha-
sized that varus deformities conform to an imaginary circle with a patient
placed inside the circle (circular legs = bowed legs, cubitus varus = a bowed
elbow).
This may help some learners, particularly for the externally apparent joints
(elbow, knee, ankle). Logically, the opposite deformity (valgus) does not con-
form to a circle.
For most orthopedic learners, hearing and using the terms again and again
while viewing the appropriate x-rays seems the best way to master orthopedic
language. Seeing and learning about the complications in children’s fractures
that are best described by varus and valgus helps. For example, a poorly treated
supracondylar fracture almost always heals in cubitus varus (Fig. 3-1). Similarly,
inattention to a femoral neck fracture will lead to coxa vara (Fig. 3-2). Coxa
vara is also seen secondary to skeletal dysplasia and in an idiopathic form.
Sagittal Plane Descriptions
Sagittal plane abnormalities related to fracture position and fracture reduction
can be efficiently described but the use of interchangeable terms has caused
confusion. The confusion is due to a lack of standardization as to whether one
should describe fracture deformity by the direction of the apex of the deformity
or by the displacement of the distal fragment.
Distal both bone fracture deformities are common and the confusion that
exists in describing them is understandable. The most common pattern is a fall
 Varus,Valgus, and the Midline

Varus Deformities
(Conform to a circle)

Valgus Deformities
(The opposite)

Varus and Valgus

Terminology and
the Midline
This illustration has
knock knee (genu
valgum) By definition
valgus means the
more distal segment
is deviated laterally
(further from the
midline) as compared
to the proximal seg-
ment.

One of the many methods used to learn the application of varus and valgus in orthopedics.
(After Salter RB.Textbook of disorders and injuries of the musculoskeletal system, 3rd ed. Williams & Wilkins, Baltimore, 1999)

31
32 Table 3-1 How to Describe This Fracture?
Orthopedic Literacy: Fracture
Description and Resource Utilization
INCORRECT
“The fracture is dorsally
angulated.”

CORRECT
“The fracture is dorsally dis-
placed with apex volar an-
gulation”—Some might say
“dorsally tilted.”

describe
Always reference
to
&**
in proximal
distal
“‘Posterior dislocation of the knee’
on an outstretched hand (so-called FOOSH injury) with the fracture occurring
means that the tibia is lying poste- 3-4 cm above the physis, with the distal fragments displacing dorsally, and with
rior to the femur” volar angulation at the fracture site (Table 3-1).
Most orthopedists like to describe this fracture by describing both the angu-
lation and displacement and might say “displaced distal forearm fracture with
volar angulation of 45°.” Perhaps even clearer, one could say “dorsally displaced
distal forearm fracture with 45° of apex volar angulation.” Although some vari- Do Not
ance is accepted, the language clearly defines the fracture.
The opposite deformity also occurs at the same level (so-called Smith vari- use T a

ant) with apex dorsal angulation and the distal fragment displaced volarly. Smith
in

Also by convention, when describing a joint dislocation, for example, when pedswtho
stating that “the knee is dislocated posteriorly”—“posterior” applies to the distal
member as compared to the proximal. “Posterior dislocation of the knee” means
that the tibia is lying posterior to the femur.

Other Descriptions
The concept of dorsal and ventral terminology is related to embryologic devel-
opment and innervation. The segment of the leg innervated by the dorsal divi-
.
sion of motor roots (back of leg; hamstrings, gastroceles) is considered dorsal
(or posterior), whereas the ventral division of motor roots innervates the ventral
(or anterior muscle groups—quadriceps, anterior tibial). Unfortunately the em-
bryologic rotation of the limb makes clear understanding and application of
this concept difficult. Simpler terminology is therefore used.

Lower Extremity Descriptions

Figure 3-3. Most would describe this
fracture as having anterior angulation.
Lower limb issues relate to whether a fracture is angulated anteriorly or posteri-
orly (Fig. 3-3). In the femur, one commonly describes a fracture as being in
varus or valgus, with anterior angulation or posterior angulation (with dorsal
and ventral less well understood).
As one moves distally the term recurvatum (angulated posteriorly) and
procurvatum (angulated anteriorly) are sometimes used. This term is often used
for distal femoral fractures, tibial fractures, and deformity about the knee due to
physeal closure (e.g., recurvatum due to tibial tubercle fracture with physeal
closure) (Fig. 3-4).
 33
Fracture Language

Figure 3-4. This could be described as a “posterior bow at the knee” but is more com-
monly described as genu recurvatum in this case due to traumatic closure of the tibial tuber-
cle (growth plate).

Thus “curvatum” terminology is more widely used in the lower extremity,

likely because the terms dorsal and ventral are less well visualized in the biped
(upright species), as compared to dorsal and volar in the forearm. In some parts
of the world, an “apex ventral deformity” of the lower extremity might be easily
understood as occurring on the anterior surface of the femur or the tibia; how-
ever, this terminology is not used in North America.
An example of how this language is used would be a distal tibial fracture,
perhaps 4–5 cm above the ankle. If this fracture had an anterior angulation, it
would be described as being in procurvatum (with apex anterior angulation).
More commonly, this fracture has a posterior angulation (Fig. 3-5). If such frac-
tures are casted with a neutral foot position, muscle and tendon forces tend to Figure 3-5. This tibial fracture has apex
posterior angulation (recurvatum). Reduc-
worsen the recurvatum or posterior angulation. Initial casting in equinus is ad- tion plus casting in equinus will be required.
vised (also see Chapter 15).

Foot Language
Language describing foot deformity leads to another level of confusion because
the foot is generally perceived to be at right angles to the trunk and legs, thus
the terms dorsal and ventral are hard to visualize. Do you visualize the bottom
of your foot as being ventral or dorsal?
Angulation in the sagittal plane in the foot is sometimes described as apex
dorsal or plantar angulation. Yet from a classic anatomic view point the bottom
of the foot is its dorsal surface. Dorsal and plantar have been adopted as the Figure 3-6. Dorsal and plantar describe
most logical descriptions, although not anatomically correct. If humans only the foot in stance phase.
swam, dorsal and ventral would suffice (Fig. 3-6).
The term adduction and abduction are often used to describe forefoot posi-
tion. Adduction implies that the distal segment is more toward the midline as
compared to the proximal segment. Deviation away from the midline is called
abduction.
A congenital deformity of the foot with medial deviation of the forefoot is
referred to as either metatarsus varus or metatarsus adductus (Fig. 3-7). The
varus term is applied because of the bowed deformity of the foot with the con-
vexity appearing laterally (thus conforming to a circle). Adductus can also be
used because the distal portion of the foot is more medial than the proximal
segment. A first metatarsal fracture can produce an adduction deforming (or be
described as in an adducted position Fig. 3-8).
Figure 3-7. Common terms to describe the foot. Are these coronal or axial deviations? If the patient is standing, the axial plane prevails.
“Terms such as varus, valgus,
procurvatum, recurvatum,
etc. are confusing and
instead should be defined in
terms that most parents use
in day to day conversation
(‘bowed’, ‘angled’, etc.)”
Figure 3-8. Adduction deformity in a first
metatarsal fracture.
34
Deformity of the great toe with angulation of the metatarsal phalangeal joint
(bunion deformity) is referred to as hallux valgus—the more distal segment
(toe) deviates laterally making the metatarsal head translate medially (Fig. 3-9).
LANGUAGE AND FAMILIES
A growing area of orthopedic language application relates to discussions with
patient, parents, and relatives. Sizing up the child and family you are treating
includes assessing their knowledge base, allowing you to adopt terminology that
is clear, descriptive, and appropriate for their level of understanding.
Internet savvy families often make special demands, mandating that you
communicate at their newly attained level of communication. A gracious ap-
proach is required, acknowledging what they have learned and then adding
your wisdom, gained through experience. Much can be learned by listening to
(and briefly reviewing the hard copies) all that has been gathered by the Internet
savvy parent. I usually make a copy for the chart.
On entering the consult room, one quickly determines whether the child
and the parents should be communicated to in a more traditional method rely-
ing on lay terminology versus a more high tech “parental Internet knowledge”
manner. As a general principle, it is usually best to use simple terms until the
conversation leads elsewhere. For example, when describing a physeal injury it
may be better to use the term “growth plate.” Terms such as varus, valgus,
procurvatum, recurvatum, etc. are confusing and instead should be defined in
terms that most parents use in day-to-day conversation (‘bowed’, ‘angled’, etc.).
When discussing diagnostic studies such as MRIs or CTs, most patients light
up since they have a relative who had such a study or they have seen a TV show
that has presented the concept. Of course, everybody wants one (Fig. 3-10). To
limit the voracious consumer demand for these studies, a brief explanation con-
cerning the risk versus benefit issues of such a test (especially as concerns poten-
tial risks to the child—radiation for CT scan) is more effective than stating that
the test is too expensive, which only leads to a feeding frenzy. When holding off
on ordering a CT or MRI study you should assure the family that if the
straightforward tests (exam, x-ray, complete blood count, sed rate, C-reactive
protein) do not solve the problem that you will then order the special studies.
Language at Follow-Up 35
Language and Families
At follow-up for femoral fractures and other lower extremity physeal injuries,
one commonly assesses limb length difference. I prefer the term “difference”
rather than shortening. If one is describing limb length difference to an assistant,
I find it better to state that one limb is longer than the other. “Short” has a nega-
tive connotation that can lengthen your explanatory day. Also with femoral frac-
tures, the injured limb may in fact be the long one (due to growth stimulation).
Radiographic concepts such as angulation, bayonet apposition, and other is-
sues plague the orthopedic surgeon-parent discussions. One must be cautious
how and where one uses films to explain a child’s orthopedic problem. In gen-
eral, x-rays should be taken into the examination room because they greatly
simplify your explanation. If fracture films show complete bayonet apposition
and you choose to demonstrate them (in all their glory), you must be prepared
for a lengthy explanation in many cases.
We keep a set of teaching films in our office and clinic so that we can quickly
show an example of another patient who had a similar type of injury (and in
which the fracture remodeled Fig. 3-11). On a busy day, you may decide that Figure 3-9. Hallux valgus—the toe devi-
the art of children’s orthopedics (on that day) includes not showing the bayonet ates laterally in relation to the more proxi-
apposition film on a fracture check visit, but it must be in hand if the parents mal segment of the foot.
request a review. (Usually they have already reviewed the films while returning
from the x-ray department.)

The Modern Communication Era

The era of Internet image transmission has arrived and will revolutionize fracture At Injury
language and communication. The future (really current) era allows a home, au-
tomobile, or satellite office positioned orthopedic surgeon to both listen to the
history and review diagnostic x-ray images from a distance. This will radically
improve analysis of cases and allocation of resources, allowing accurate decisions
about “splint and send to clinic later this week” versus “splint and bring to clinic
tomorrow” versus “needs to be admitted and go to the operating room.”
As previously noted, this simultaneous discussion of the radiograph with the
primary care physician who is analyzing the patient will greatly improve physi-
cian musculoskeletal education allowing the “orthopedic terminology” (dorsal
and volar angulation, dorsal displacement, varus, valgus, antecurvatum,
retrocurvatum, etc.) to be better understood by primary care colleagues. Early
Healing

1 Year Later

Figure 3-11. When parents get worried

about what we consider acceptable angula-
tion or apposition, we show them films
from our teaching file that demonstrate
Figure 3-10. This child’s parents insisted on a spine MRI (occasional backache). Amazingly a the child’s ability to remodel. This case
syrinx was found. The wide availability of sophisticated diagnostic methods sometimes pro- demonstrates how a femoral fracture in an
duces more questions than answers. infant will remodel.
36
Orthopedic Literacy: Fracture
Description and Resource Utilization
“Consumer acceptance of
the digital revolution will
require education since
many patients still prefer to
‘see the orthopedic doctor’
on the same day”
“This is a severe
supracondylar fracture.
You must see the child
urgently in your ER”
Figure 3-12. This was called in as an
acute supracondylar fracture requiring
emergent surgery. In fact this is a lateral
condyle fracture and surgery could be
done anytime in the next 4 to 5 days.
“The development of
telecommunication methods,
which allow transmission
of digital x-ray images to an
orthopedic surgeon’s auto-
mobile, home, or offsite
office will improve com-
munication efficiency”
Consumer acceptance of the digital revolution will require education because
many patients still prefer to “see the orthopedic doctor” on the same day. Eco-
nomic and outcome studies will help correct this once the true cost of having a
specialist see even a modest injury on the same day becomes apparent.
FRACTURE DESCRIPTION AND
RESOURCE UTILIZATION—WHAT
REQUIRES EMERGENCY REDUCTION?
“This is a severe supracondylar fracture. You must see the child urgently in your
ER” (Fig. 3-12). As a consequence, the receiving surgeon’s operating room
(OR) staff is kept past their regular hours—sometimes on overtime pay—await-
ing the urgent case only to find on the patient’s arrival that the fracture was not
severe or was a lateral condyle fracture, either of which could have been seen in
the clinic the following day—saving thousands of dollars.
The growth of emergency medicine as a specialty as well as more prevalent
urgent care centers, combined with the traditional pediatric trauma initially
seen in the office of family practitioners and pediatricians, emphasizes the need
for improved musculoskeletal communication skills among non-orthopedic
surgeons.
Part of the problem relates to the limited musculoskeletal education pro-
vided to North American medical students. The crowded medical school cur-
riculum, focused on basic science and molecular medicine, provides little time
for musculoskeletal education, despite the fact that 30% or more of urgent
medicine deals with musculoskeletal issues.
Orthopedic surgeons can help to improve this situation by encouraging in-
creased attention to musculoskeletal disease education for the medical school
curriculum and also by providing primary care, family practice, and pediatric
residencies with the opportunity for clinic exposure and rotations on an ortho-
pedic service. More practically, the orthopedist can take the time to discuss the
clinical and x-ray findings with his/her colleagues when arriving to assess an
emergency case.
As noted previously, accurate description of the fracture type and its severity
has great economic consequence. Is the fracture open, thus requiring emergency
débridement? As already noted, descriptions of deformity versus angulation are
often confusing. Perhaps the best that one can expect is an accurate description
of the degree of angulation of the fracture. Whether the displacement or angu-
lation is dorsal or volar (upper extremity) or anterior or posterior (lower extrem-
ity) is likely less important for the initial discussion.
The development of telecommunication methods, which allow transmission
of digital x-ray images to an orthopedic surgeon’s automobile, home, or offsite
office, will improve communication efficiency.
WHAT REQUIRES EMERGENCY
REDUCTION?
The topic of orthopedic language and children’s fracture treatment logically
leads into efficient resource utilization. In this section I will present a few notes
on treatment urgency, which will also be mentioned in Chapter 4.
Fracture Reduction Urgency
The urgency for fracture treatment in children has varied greatly. Often deci-
sions about urgency are made according to the type of institution providing
treatment and/or the social structure of the family. A commonly quoted system 37
is that of John Royal Moore in Philadelphia who held a children’s fracture re- What Requires Emergency Reduction?
duction clinic every Thursday (see Chapter 4). Children injured throughout the
week were consolidated and treated on a single day. Obviously, true emergen-
cies were excepted.
Traditionally, orthopedic practices probably have provided same day reduc- “The development of large
tion and treatment for many fractures, except for cases where swelling could not children’s hospital treatment
allow it. A child injured in school would hope to see an orthopedic surgeon that
day with a cast applied and/or a reduction performed as needed. Splinting alone
centers particularly with
would be used only if swelling was extreme. resident manpower available
The development of large children’s hospital treatment centers particularly has led to an exaggerated
with resident manpower available has led to an exaggerated sense of urgency re-
garding the need for acute reduction. Other factors have also contributed to sense of urgency regarding
this. These would include the development of emergency medicine as a spe- the need for acute reduction”
cialty and also the use of emergency rooms (ERs) as urgent care centers by a
large segment of the population, particularly the underinsured.
Patients arriving early in the evening are assessed by the emergency depart-
ment attending and determined to need a reduction. With a resident available, it
seemed only logical to get a consult and, if feasible, reduce the fracture on an ur-
gent basis, using conscious sedation anesthesia. The problem lies with late ar-
rivals, need for a certain length of nothing by mouth (NPO) status (4-6 hours),
even for conscious sedation, and the 80-hour resident work week. Suddenly, one
is faced with a child arriving at 9:00 p.m. who cannot be reduced until 3:00 a.m.
The pattern noted previously has led to an over-utilization of an institution’s
resources for fracture care and reductions. Clearly, nighttime care is more ex-
pensive than elective, daytime care and passing the load to residents is not the
appropriate solution. Some of our solutions to this dilemma are presented in
Chapter 4.

Open Fractures
A cardinal rule of fracture care at any age has been that an open fracture must
be taken to the OR and débrided within 6-8 hours of the injury (Fig. 3-13).
Classic literature suggested that if this time limit was not met, infection and
even osteomyelitis were more likely. Skaggs et al. as well as Yang suggested a
change in this protocol, particularly in Type I injuries. These publications sug-
gest that if the patient has a clean wound, the wound is cleansed and sterilely
dressed, and the patient is given intravenous antibiotics, the operative débride-
ment of an open fracture can perhaps be done the next morning. This is highly
controversial and should be applied only after careful study of the literature, Figure 3-13. Open fracture requires ur-
gent surgery for débridement as well as re-
one’s experience, and the institutional standards.
duction and stabilization.

Supracondylar Fractures
A second urgency issue concerns treatment of supracondylar fractures that can
be quite severe and that, in very difficult cases, can have neurovascular compli-
cations. Accordingly, this fracture has been given a great deal of urgency and
traditionally it has been advised that the child have urgent reduction plus pin-
ning on arrival (Fig. 3-14).
Because large volumes of patients with supracondylar fractures have been
concentrated in children’s centers, it has been demonstrated that these patients
can, in most cases, be splinted with reduction the next day.
The study by Gupta et al. from Los Angeles clarifies that most supracondylar Figure 3-14. Severe Type III supracondy-
fractures, even Type III injuries, providing they do not have a significant neuro- lar fracture of the humerus. When must
logic deficit or skin tenting on arrival, can be safely splinted and then treated this be reduced as a super-emergency?
38
Orthopedic Literacy: Fracture
Description and Resource Utilization
“Neither a practicing
orthopedic surgeon nor an
orthopedic resident will
want to reduce a fracture at
these hours if safe
alternatives are available”
Figure 3-15. Does this fracture mandate
urgent formal reduction at 3 a.m.? John
Royal Moore would have suggested that it
doesn’t. If you ask your resident to do this
reduction at 3 a.m. in the ER, he or she will
not be available for surgery the next after-
noon (and may miss doing an important
case).
“...as the true cost of night
and weekend care becomes
apparent, and insurance
schemes further involve
families in sharing cost, it
will become apparent that
definitive treatment by a
specialist in the middle of
the night (or early in the
morning) is not sustainable”
surgically within the next 24 hours, at a time that is more convenient for the
surgeon (and economical for the hospital) while still producing good results.
Clearly, a careful assessment of the patient needs to be made and splinting
needs to be done in relative extension to avoid increasing the tension on the
elbow hematoma. Often about 30° of flexion is the ideal position of splinting.
The child should be admitted to the hospital for monitoring.
Other Angulated Fractures
Because most supracondylar fractures can be splinted and treated within the
next day; clearly moderately angulated forearm fractures do not require an im-
mediate reduction at night. Our hospital has a very large number of such pa-
tients, and if the patient comes in early at night on an empty stomach, it is easy
to give conscious sedation and reduce the fracture.
Because modern conscious sedation protocols (Chapter 4) are progressively
geared toward making the child NPO for 6 hours prior to sedation, the child
who arrives at 9:00 at night might not be able to have a reduction until 3:00 in
the morning. Neither a practicing orthopedic surgeon nor an orthopedic resi-
dent will want to reduce a fracture at these hours if safer alternatives are available.
A moderately angulated forearm fracture can simply be splinted and reduced and
casted sometime within the next several days or even a week (Fig. 3-15).
Many private orthopedic practices and institutions have already had these
more practical policies in place for some time. The 80-hour work week regula-
tions for orthopedic residents will nudge training centers into this more realis-
tic view of fracture reduction urgency. These less urgent policies allocate re-
sources better and allow swelling to subside before the formal casting occurs.
Another advantage in the North American resident training program setting is
that the actual manipulative reduction can be carried out when senior staff are
available, thus allowing proper supervision, as well as appropriate billing for
rendering of services.
EDUCATING FAMILIES REGARDING
URGENCY
Systems that are in the habit of providing overly urgent definitive care when it is
not scientifically required or justified will take some time to reeducate their con-
sumers when making the transition to a less urgent philosophy. The first task is
to educate your emergency physician colleagues (both in your hospital and else-
where). Giving an instructional course on how to splint makes a good start.
Often families believe that their child’s fracture must be set immediately and
are not happy unless their child is in a cast before the sun sets (or for late ar-
rivals, the sun rises the next day). Families must be educated concerning the
safety and value of delayed reduction and casting, and much of this instruction
will come from the ER staff (Table 3-2). Also you must be certain that your of-
fice or clinic has readily available openings for appointments (and reductions)
within the next few days.
The first advantage that can be pointed out to the family is that casting will
be safer after swelling has receded. Careful splinting with casting in 48–72
hours allows the swelling to diminish, allowing a cast to be applied that often
will not need to be split or bivalved. This in many cases will save an added visit
to the orthopedic office.
A second advantage is that they will have definitive treatment during day-
time hours by the most experienced team. This often includes the most experi-
enced cast technicians and orthopedic surgeons.
 Table 3-2 Advantages of Splinting Fractures 39
(with formal reduction later) Suggested Readings

Safer—allows swelling to decrease

Definitive treatment in daytime hours—by experienced team
Correct billing for reduction plus casting

Finally, as the true cost of night and weekend care becomes apparent, and in-
surance schemes further involve families in sharing cost, it will become appar-
ent that definitive treatment by a specialist in the middle of the night (or early
in the morning) is not sustainable. Those who demand emergent reduction
when it is not really required will need to bear the added cost.

SUMMARY
In summary, proper use of orthopedic language and technology makes chil-
dren’s fracture care more efficient. The transmission of digital images will allow
the final decision makers to determine how severe the fracture is and whether or
not urgent reduction is required, even if the treating surgeon is far from the
hospital. Splinting protocols will be improved. Fracture reduction can then be
performed during daytime hours. Late night and early morning hour care can
be allocated to truly emergent injuries (severe open fractures, fractures with vas-
cular compromise).

Suggested Readings
Diab, M. Lexicon of orthopedic etymology.
Harwood Academic Publishers 1999.
Gupta N, Kay RM, Leitch K, Femino JD,
Tolo VT, Skaggs DL. Effect of surgical
delay on perioperative complications and
need for open reduction in supracondylar
humerus fractures in children. J Pediatr
Orthop. 2004 May-Jun;24(3):245-8.
Gustilo RB, Anderson JT. Prevention of in-
fection in the treatment of one thousand
and twenty-five open fractures of long
bones: retrospective and prospective
analyses. J Bone Joint Surg AM. 1976
Jun;58(4):453-8.
Harley BJ, Beaupre LA, Jones CA, Dulai SK, Yang EC, Eisler J. Treatment of isolated type
Weber DW. The effect of time to defini- I open fractures: is emergent operative
tive treatment on the rate of nonunion debridement necessary? Clin Orthop.
and infection in open fractures. J Orthop 2003 May;(410):289-94.
Trauma. 2002 Aug;16(7):484-90.
Salter RB. Textbook of disorders and in-
juries of the musculoskeletal system 3rd
ed. Williams & Wilkins—Baltimore,
1999.
Skaggs DL, Kautz SM, Kay RM, Tolo VT.
Effect of delay of surgical treatment on
rate of infection in open fractures in chil-
dren. J Pediatr Orthop. 2000 Jan-
Feb;20(1):19-22.
 Emergency
4
Fracture Reduction
Philip Stearns m Dennis Wenger

• Introduction—Fracture Treatment 41
• Developing a System 43
• Analgesia for Reduction 47
• Manipulative Reduction 5

INTRODUCTION
Traditionally, simple minimally displaced or nondisplaced fractures in children
“Those who do not
were treated in the emergency room (ER) with minimal or no anesthesia. Mod-
erately displaced fractures were sometimes treated in the ER with local anesthe-
feel pain, seldom
sia (hematoma block, IV lidocaine methods); however, most moderate and all think that it is felt”
severe fractures were treated in the operating room (OR) with general anesthe-
sia. With the development of new methods for analgesia and the availability of —DR. JOHNSON
compact digital imaging units, many significantly displaced and angulated chil-
dren’s fractures can now be treated in ERs, clinics, and office-based treatment
centers. This has reduced the number of reductions performed in the OR, free-
ing those rooms for more severe cases.
This chapter will clarify how our hospital has developed and applied these
new methods in a county of 3 million people and an emergency setting in
which 4,000 new children’s fractures are evaluated and treated annually. Key el-
ements in this evolution include:
! A progressive orthopedic surgery group interested in safe, cost-effective frac-
ture care that avoids OR use and hospitalization.
! In busier programs: residents, nurse practitioners (NP), and physician assis-
tants (PA), trained in fracture care.
41
42
Emergency Fracture Reduction
“With the development of
new methods for analgesia
and the availability of
compact digital imaging
units, most significantly
displaced and angulated
children’s fractures can now
be treated in ERs, clinics,
and office-based treatment
centers”
ER or ED
Common emergency rooms
have grown in size and com-
plexity, they have often become
departments. As such, they
often ask that they be known
as the “ED” (emergency de-
partment). Yet the common
medical culture maintains
“ER” (witness the popular tel-
evision show). We try to use
the language most commonly
used in this text (which in our
case is ER)
! Internet digital transfer of images.
! Advanced Life Support (ALS) and Pediatric Advanced Life Support (PALS)
certified doctors, nurses, and medical personnel—full-time ER medical staff.
! Development of safe, effective, conscious sedation anesthesia techniques
(Fig. 4-1).
! Compact portable, low radiation, digital image intensifying machines to
monitor reduction.
! Certified orthopedic technicians.
The combination of these factors has revolutionized fracture care efficiency in
children.
Current Trends
Today, most children’s fractures can be safely reduced in the ER ranging from
forearm fractures to femur fractures. Initially, the treating orthopedic surgeon
had the sole responsibility for analgesia, reduction, and casting. With newer
methods, most ERs can provide an environment that allows a systematic “team
approach” for fracture reduction. Conscious sedation can be administered, a
nurse can monitor the patient, and a portable image intensifier allows one to
monitor fracture reduction (Fig. 4-2).
Fracture Care Involving Orthopedic Residents
in Training
In centers with resident training programs, the new methods have allowed res-
idents to provide efficient fracture care, decreasing the need for staff orthope-
dic surgeons to be present for every reduction. Traditionally, most North
American centers required a staff orthopedic surgeon to be present for all
reductions performed in the OR. The presence of supervising, attending ER
physicians (who provide overall supervision for the case) now allows resident
fracture reduction in the ER with the on-call staff orthopedic surgeon in atten-
dance only for problem cases.
Figure 4-1. Ketalar (Ketamine) alone has Figure 4-2. Compact image intensifiers
proven to be a very safe agent for conscious allow accurate monitoring of reductions
sedation in children (see Green et al.— with minimal radiation exposure.
Suggested Readings).
 Internet transfer of digital x-ray images allows even more efficient off-site 43
staff supervision of resident, NP, or PA activity. Developing a Fracture Treatment
System

Nurse Practitioners and Physician Assistants

The development of mid-level providers (NP, PA) in specialty care makes children’s
fracture care more efficient in centers with the volume to support such a system.
In our center, the orthopedic staff train not only orthopedic residents but
also mid-level providers (NP/PA) in fracture management. This has helped us
deal with new resident work requirements and with increased patient volume.
Proper training and supervision allows mid-level providers to manage children’s
fractures safely and efficiently.

DEVELOPING A FRACTURE TREATMENT

SYSTEM Mid-level Providers:
To treat a high volume of fractures, an efficient system that coordinates care be- Who Are They?
tween the ER staff and the orthopedic team should be established. In this sec- We use this odd term to describe physi-
cian assistants and nurse practitioners
tion, we will describe the methods that we have developed and use at Children’s who have become experts in children’s
Hospital-San Diego. These methods can also be applied in a specialized fracture orthopedic care. Our service trains
reduction clinic model, if appropriately trained personnel are available to man- them as much as residents are trained.
age conscious sedation (see Suggested Readings—Smith). After about one year of training in the
Efficient fracture care in a busy children’s hospital requires a team that can orthopedic clinics and observing in the
ER, they become savvy enough to work
focus on musculoskeletal problems. In our system, this team consists of an at-
in the ER eventually becoming experts
tending surgeon, an orthopedic resident, a mid-level provider (NP or PA), and in fracture reductions.
an orthopedic technician.
Photo courtesy of P. Stearns.

Arrival
Patients arrive to our ER through self-referral, by referral from an outside facil-
ity, or from their primary doctor. When a child is sent from an outside facility, a
call has usually already been made notifying either the orthopedic team or the
ER staff. In some cases, the team may decide, after talking with the referrer, that
an expensive emergency visit is not required (Table 4-1).
Simple fractures (or suspected fractures) should be managed with a splint
and sent to the outpatient clinic or office within a few days. Of course this is
often hard to ascertain by telephone. We note errors weekly. A small puncture
wound may not be recognized as an open fracture and a 1 a.m. transfer for a
“severe supracondylar fracture” is often just a buckle fracture.
Not all fractures require reduction and not all patients need treatment in the
middle of the night. Even in our very busy system, the full team is available
only until 11 p.m. Fractures that are only modestly displaced or angulated do
not require reduction at a very late hour. Such cases can be splinted by your ER
staff and brought back for formal reduction in a few days. John Royal Moore
This is sometimes difficult to implement because parents are anxious and Moore, a prominent orthopedic sur-
geon from Philadelphia, created and im-
concerned about their child’s injured extremity. Although most parents want an
plemented an effective fracture reduc-
immediate reduction, in almost every type of fracture, there is no scientific evi- tion clinic that met only once a week
dence that immediate reduction provides a better result (see insert about John (every Tuesday). His method proved to
Royal Moore in Philadelphia). be safe and effective and its principles
Once a patient has been accepted for treatment, both the orthopedic team are still used today. Splinting of small
and the ER staff should be notified so that triage can be started immediately on fractures with reduction (if needed) in
3 to 5 days allows swelling to subside,
arrival. This ensures prompt treatment and limits unnecessary waiting time in making casting safer.
an already busy ER.
44 Nurse Triage
Emergency Fracture Reduction
On arrival, the emergency department triage nurse can assess the child and usu-
ally order the appropriate x-rays (sometimes after brief consultation with the
ER staff or an orthopedic team member).

ER Physician Assessment
Because the child has entered the ER, most systems mandate that each child be
briefly evaluated by the ER physician. The ER physician ensures that there is no
underlying systemic injury and evaluates injury circumstances, social dynamics,
and the child’s overall health.

Table 4-1 Guidelines for Referring Doctors, Clinics, and ERs

Send Urgently or Splint and Refer Later?

To ER (Urgent) Splint—refer within 48 hrs Splint—refer within 1 week

FOREARM

Nerve at risk Mild translation or angulation Minimally displaced fractures

TIBIA

Open fx or compartment at risk Mild angulation—low energy Non displaced fracture

OTHER

Major joint dislocations Intra-articular fractures 99% of clavicle fractures

 45
Developing a Fracture Treatment
TECHNIQUE TIPS: System
Pathway—Children’s Fractures in the ER
46 Orthopedic Assessment
Emergency Fracture Reduction
With the patient now under orthopedic care, a history and physical are performed
with special focus on issues such as neurovascular compromise and whether the
fracture is open. A neurovascular assessment can be difficult in a young child who
is in pain. You should document only that which is documentable. For example,
in a 2-year-old child with no ulnar nerve function post-reduction, it is important
not to have stated that it was functioning prior to reduction if you were uncertain;
better to have written that accurate documentation was not possible.

“One must recognize that
not all 8 year olds have the
same temperament; different
children react differently to
the same type of fracture”
Treatment Strategy
In busy centers where the attending surgeon and the resident are often busy in the
operating room, the role of the NP/PA becomes important. In our hospital, the
NP/PA is trained to reduce/treat children in the ER with straightforward prob-
lems, after discussing the case with the resident or staff. On a busy day, films can be
taken to the orthopedic resident/staff who are busy in the OR (often transported
by the orthopedic technician) for a quick read and advice on treatment (Splint and
send home? Reduce in ER? Requires OR?—See technique tips pathway).
The treatment plan is implemented. All care is under the direction of the
staff surgeon who is on call and may be in the ER, in the OR, or off-site and
available by phone and/or e-mail image.

Fracture Reduction
In planning reduction, fracture location helps to decide whether conscious se-
dation in the ER is required. Most forearm fractures are good candidates
whereas femur fractures in older children (older than age 5 or so) and signifi-

Splinting Fractures
A key element to a sensible musculoskeletal urgent care well also. Training primary care doctors to splint safely is a
program is the widespread availability of safe and practical great investment toward rational fracture care.Training ses-
fracture splinting by outlying facilities. The more recently sions for referring practitioners provide a great community
available fiberglass-felt-foam composite splints (available on service that will save time, money, and frustration for you
bulk rolls) combined with an elastic wrap roll allows easy and the patient.
application for the trained orthopedist; ERs seem to do it
 Table 4-2 Reduction in ER vs OR 47
Analgesia for Reduction
Good Candidates—ER Reduction OR Reduction Preferable

Wrist fractures Complex tibia fractures (older child)

Forearm fractures Femur fractures (older child)
Hand/foot fractures Open fractures
Infant femur fractures Fractures with neurovascular compromise

Table 4-3 Should Parents Be Present for Orthopedic Reductions?

(In our center we ask the family to leave—Some of our reasons are listed below)
Grotesque maneuver required to lock fracture ends

Audible noises (crunching of bone ends)

Seemingly aggressive face or noises (suggests an “assault”)

Risk of fainting (parents)

A tough reduction is like an operation (parents should not attend either)

Focus on reduction better with no outside “audience”

cantly angulated tibial fractures are often best treated in the OR with general
anesthesia (Table 4-2). One must recognize that not all 8 year olds have the
same temperament; different children react differently to the same type of frac-
ture. Therefore, the decision about anesthesia methods should be adjusted ac-
cording to the child’s temperament and family dynamics.
Also, parental anxiety may determine where the fracture should be reduced “We believe that the person
(Table 4-3). We ask the parents to go to the waiting room while the actual re- who performs the actual
duction takes place (to avoid their exposure to the sounds and apparent aggres-
sion required to reduce a stubborn fracture). A few insist on staying; in such manipulation deserves the
cases, OR reduction may be better and the treating surgeon should offer this degree of privacy which
option. We believe that the person who performs the actual manipulation de-
serves the degree of privacy that allows optimal performance. The patient’s re-
allows optimal performance”
sult may depend on this.

ANALGESIA FOR REDUCTION

No Anesthesia
For fractures that require minimal manipulation, some children can tolerate
casting and molding without anesthesia. The child and parent need to under-
stand and be willing to accept that there will be mild pain with this technique.
Often the child will agree and select this option once understood that formal
analgesia requires needle sticks. After successful completion of this artful ma-
neuver, the child is praised for cooperation in achieving good fracture position
with no needles.
48 Oral Medication
Emergency Fracture Reduction
A second option for fractures that require minimal manipulation can include
the combination of acetaminophen (Tylenol) with codeine (0.5-1 mg/kg) and
oral midazolam (Versed) (0.3 mg/kg). This choice is sometimes selected for an
anxious patient that in other circumstances would be casted without analgesia.
“Every treating orthopedist The cast is placed with no preliminary manipulation and with the “gentle re-
should develop local duction force” applied as the cast sets. ( wax
IO nyj
0.05
0 I 1
mg kg
Versed IV
-

-2
.

anesthesia skills and use

Local Anesthesia
them whenever possible”
Despite the methods that we will describe in this chapter for conscious seda-
tion, every treating orthopedist should develop local anesthesia skills and use
them whenever possible. This is even more important because some centers
apply very strict regulations regarding nothing by mouth (NPO) status (child
must have empty stomach) before conscious sedation can be given. In many
cases, deft local anesthesia skills will save you and your patient many hours and
much frustration.
The most common local anesthetic method for fracture reduction is a
hematoma block with 1% lidocaine (no epinephrine) solution directly injected
into the hematoma at the fracture site (Table 4-4). The maximum recommended
s
dose for lidocaine without epinephrine is 4.5 , mg/kg (300 mg maximum). With-
drawing blood into the syringe, the so-called blood flash, indicates correct needle
tip position and the lidocaine is then injected. Ideally, one should wait several
minutes prior to fracture reduction to allow more effective analgesia.
Hematoma blocks can be used for many fractures and can be performed
without the assistance of the ER staff (freeing them for more critical patients).
These blocks work well for forearm fractures (especially in the distal 1/3 area)
but are generally not used for larger bones such as the femur or humerus. Also,
issues of maximum dosage come in to play (risk for seizures) if one attempts to
use a hematoma block for a large bone fracture.
Lidocaine can also be used for digital nerve blocks, allowing one to reduce
various fractures of the hand (metacarpal, phalanges, nail bed injuries, lacera-
tions, MCP/IP dislocations) and foot (phalanges) (Table 4-5). One can block
each nerve bundle separately or use a single midline injection (in line with the
tendon sheath) that disperses and blocks both digital nerves.

Table 4-4 Reduction with Hematoma Block

Preparation Superficial Block Blood Flash Reduction Casting

Prep with alcohol and Using 25-gauge needle, Using 18-gauge needle, Wait a few minutes and Apply well-molded cast
povidone-iodine numb the skin around inject at fracture site perform reduction
the fracture (4-6 cc of 1% lidocaine)
 Table 4-5 Digital Block (Flexor Tendon Sheath) 49
Analgesia for Reduction
Preparation Localize Flexor Injection
Tendon

Prep with alcohol and Palpate flexor tendon Using 25-gauge needle,
povidone-iodine inject 2-3 cc of lidocaine
into the tendon sheath.
(never use epinephrine in
a finger)

Regional Anesthesia
Intravenous lidocaine block (Bier block) can be very effective for reducing
upper extremity fractures but requires special tourniquets and attention to de-
tail. The Bier block, a technique of IV regional anesthesia originally described
by August Bier in 1908, can be performed in an ER setting, office, or clinic,
thereby avoiding the OR. The arm is elevated to exsanguinate it, a tourniquet is
inflated, and dilute lidocaine is injected into a superficial hand vein. We rarely
use this method in our hospital (due to custom) but others have found it to be
highly effective in children.

Conscious Sedation
This method has revolutionized fracture care in emergency departments and
specialized fracture reduction centers (Table 4-6). Ketamine (Ketalar), the most

Table 4-6 Medications Commonly Used for Sedation

Medication Recommended Side Effects Contraindications
Initial Dose/Max Dose Precautions
Ketamine 1-2 mg/kg Hypertension, hypotension, Increased intracranial pressure
(Ketalar) respiratory depression, (ICP), seizures hypotension, CHF
laryngospasm, hallucinations

Sublimaze (oral) 10-15 mcg/kg/dose Respiratory depression, Chronic pulmonary disease

(Fentanyl) max 400 mcg/dose hypotension (CPD), head injury/increased ICP
cardiac disease

Sublimaze (IV) 1-2 mcg/kg/dose Respiratory depression, CPD, head injury/increased ICP
(Fentanyl) q 30-60 minutes prn hypotension cardiac disease

Morphine sulfate 0.1-0.2 mg/kg/dose Central nervous system (CNS) Upper airway obstruction,
q 2-4 hrs prn and respiratory depression, acute bronchial asthma,
hypotension, increased ICP, CPD, increased ICP
nausea/vomiting

Midazolam 0.05-0.1mg/kg over 2 minutes Respiratory depression, Existing CNS depression,

(Versed) max total dose 0.2 mg/kg hypotension, bradycardia glaucoma, shock
50 widely used agent, induces a state of catalepsy that provides sedation, analgesia,
Emergency Fracture Reduction and amnesia. Interestingly, this drug is used illegally on the street and is known
as “Special K” due to its relation with phencyclidine (PCP). Ketamine is well
suited for pediatric orthopedic procedures and has been shown to provide bet-
ter sedation with fewer respiratory complications [as compared to other com-
monly used agents such as sublimaze (Fentanyl)] because it preserves protective
airway reflexes (Green et al.). Ketamine can be safely given between 1-2 mg/kg
intravenously; the 2 mg/kg dose is favored by most centers.

Administration and Monitoring Sequence

Once the orthopedic team has determined the child should have conscious se-
dation, the process is then coordinated with the emergency department physi-
cians and nurses. Ideally, this is done in a single area of the ER designated for
fracture care. The orthopedic team briefly discusses the treatment plan and the
ER staff explains conscious sedation to the family. In some centers, the analgesia
is delayed for a few hours if the child had something to eat or drink to minimize
the risk for aspiration.
A physician should be available during and following the sedation. The nurse
monitors the patient. Ideally, the child’s mental status, heart rate, blood pres-
sure, respiratory rate, and oxygen saturation are monitored before, during, and
after procedural sedation. Clearly, this ideal model of comprehensive monitor-
ing is not be available in all parts of the world.

TECHNIQUE TIPS:
Patient Safety and Pediatric Conscious Sedation

Emergency cart—Must be present Oxygen and suction set-up present Monitor vital signs during sedation
in case of cardiac abnormalities at bedside in case of respiratory
induced by medication emergency

Leads to monitor ECG, heart rate, Blood pressure monitoring Oxygen saturation used to monitor
respiratory rate patient oxygen levels
MANIPULATIVE REDUCTION 51
Manipulative Reduction
Once ready for reduction, the compact image intensifier is positioned and set
up appropriately. The injury x-rays should be placed on a view box in the line of
sight of the reducer to allow better visualization and pre-planning for the three-
point reduction maneuver (we have seen fractures molded in “reverse” when
this step is skipped!). The casting materials should be within reach.
The reduction maneuver is then performed. Alignment is assessed by imag-
ing in both the AP and lateral plane, and if adequate reduction has been
achieved, a carefully molded cast is applied.

Cast Application
A cast molded according to the fracture pattern maintains alignment and pre-
vents loss of reduction.
Prior to the cast setting, alignment should again be assessed with the fluo-
roscan to ensure adequate reduction and molding. The finishing touches can
then be applied to the cast. Finally the cast is “split” (univalved) to provide room
for swelling (Fig. 4-3) (see Chapter 5). Finally, post-reduction, traditional x-rays
are usually obtained to confirm alignment and to use as a comparison at the first
clinic follow-up visit. This step is important because the compact image intensi-
fier provides only a very focal view of the fracture.

Post-Reduction Events Figure 4-3. Multi-width, commercially

available spacers used to hold the cast
Following reduction, another neurovascular assessment should be performed open once it has been univalved.This is es-
(when the child is alert) with any changes in status addressed and documented. pecially important for synthetic material
Not every child should be sent home after closed reduction. For example, a casts, which tend to spring closed after
child with a significant tibia fracture may need to be admitted overnight for ob- univalving and opening the cast.
servation to ensure that a compartment syndrome does not develop.
The parents are advised that the cast has been univalved (split) to allow for
swelling. They should expect swelling within the next 24-48 hours and are ad-
vised to keep the limb elevated. We provide a typed instruction sheet outlining
the diagnosis and treatment to the family. This sheet describes worrisome signs
and symptoms and a contact number if there are problems. We also provide a

Table 4-7 Reduction Under Conscious Sedation

IV/Meds Given Reduction Image View Well-Molded Cast Univalve

IV started by ER nurse Manipulation performed Assess alignment after Mold cast with x-ray in Univalve cast to allow
and ketamine given reduction (prior to clear view for swelling (with spacers
(2 mg/kg) casting) to hold cast apart)
52 separate instruction sheet outlining the details of cast care. A prescription for
Emergency Fracture Reduction oral pain medication is provided, usually a 3-day course of acetaminophen with
codeine elixir for smaller children or tablets for older children.

“Modern ER manipulative Follow-up Protocol

reduction of children’s Most patients are seen for a follow-up appointment within a week and typically
fractures requiring manipulation are evaluated every week for 2-3 weeks. This
fractures using conscious allows early detection of reduction loss that can sometimes be salvaged by cast
sedation has been a major wedging.
orthopedic advance”
SUMMARY
Modern ER manipulative reduction of children’s fractures using conscious seda-
tion has been a major orthopedic advance. Performed in an organized fashion,
the method is safe, efficient, and economic and saves hospital beds for more se-
vere cases. Furthermore, most children prefer to sleep in their own homes and
in their own beds!

Suggested Readings
American College of Emergency Physicians:
Clinical policy for procedural sedation and
analgesia in the emergency department.
Ann Emerg Med 31:663-667, 1998.
Bell HM, Slater M, Harris WH. Regional
anesthesia with intravenous lidocaine.
JAMA 1963:186:544-9.
Bolte RG, Stevens PM, Scott SM, Schunk
JE. Mini-dose Bier block intravenous re-
gional anesthesia in the emergency de-
partment treatment of pediatric upper-
extremity injuries. J Pediatr Orthop,
1994 Jul-Aug;14(4)534-7.
Furia Jp, Alioto RJ, Marquardt JD. The
efficacy and safety of the hematoma
block for fracture reduction in closed,
isolated fractures. Orthopedics, 1997
May;20(5):423-6.
Green S, Nakamura R, Johnson N. Keta-
mine sedation for pediatric procedures:
Part I, a prospective series. Ann Emerg
Med 19:1025-1032, 1990.
Green S, Nakamura R, Johnson N. Keta-
mine sedation for pediatric procedures:
Part II, review and implications. Ann
Emerg Med 19:1033-1046, 1990.
Holmes C. Intravenous regional anesthesia:
useful method of producing analgesia of
the limbs. Lancet, 1963;1:245-7.
Jordan R, Rodriquez E. Contemporary
trends in pediatric sedation and analgesia.
Emergency medicine clinics of North
America v20, #1. Feb 2002.
Smith J, Gollogly S, Clark N. Assuming the
burden of pediatric fracture care in a chil-
dren’s medical center . . . Efficiently! A
model for a pediatric fracture clinic.
COMSS poster No. P489 - POSNA.
 Casts for Children’s
5
Fractures
Dennis Wenger m Mercer Rang

• History 54
• General Principles of Cast Application 55
• Cast Splitting and Removal 58
• Upper Extremity Casts 60
• Lower Extremity Casts 64
• Cast Wedging 67
• Hip Spica for Femur Fractures 69
• Cast Complications 69

Predictable application and maintenance of complication-free casts in children

is a slowly learned art and craft. In contrast to adult patients, in whom immobi- “Show me your cast
lization may produce osteopenia and joint stiffness, children rarely suffer long-
term effects from typical periods of cast immobilization. Instead, children have and I’ll tell you
a special set of complications, including poor application, poor fit, and loose
casts that slide off. Physicians often fail to understand the effect that the carefree what kind of
personality of a child has on the life, durability, and function of a cast. Also,
children often do not complain if a cast is tight or produces ulceration with the orthopedist you are”
damage noted only when the cast is removed.
This chapter is intended to present general principles for safe, predict- —CALOT
able cast application for fractures in children and to demonstrate the many
53
54 techniques we have developed at Children’s Hospital—San Diego to make the
Casts for Children’s Fractures use of synthetic cast materials safe and preditable.

HISTORY
Immobilization for fracture treatment can be traced to antiquity. Traditional
methods included use of (a) muslin reinforced with egg whites or starches and
(b) soft wood splints. Plaster of Paris was first used in the late 18th century by
the Turks to immobilize limb fractures. The limb was placed in a box that was
then filled with plaster—an awkward, bulky process.
Military surgeons were the first to push for less cumbersome methods of
fracture immobilization with Mathijsen credited with the first use of plaster of
Paris dressings in 1852. In his process, the plaster of Paris was applied to muslin

Anthonius Mathijsen
Casting in Children’s Orthopae- Anthonius Mathijsen (1805-1878), a Flemish
dics. This lovely photograph, taken army surgeon, was the first to use plaster of
in front of the Hospital for Sick Paris impregnated in rolls of linen cloth that
Children (Toronto) in about 1915, could be rolled onto the limb. In his first publica-
demonstrates a child in corrective tion in 1852 he noted that his special bandages
casts for clubfoot, attended to by hardened rapidly, provided an exact fit to main-
her nurse. (Reproduced courtesy tain reduction, and could be easily windowed or
of Mercer Rang.) bivalved.

Casting Materials Timeline

From the beginning of time, sticks and mud and cloth have been used to stop fractures from moving about.We have knowl-
edge only of recent events.
400 BCE Hippocrates describes splints.
970 CE In Persia, Muwaffak advises coating fractures with plaster.
1740 As a child Cheselden (Britain) has a fracture treated by a bonesetter with bandages dipped in egg white and
starch.When Cheselden becomes a surgeon, he introduces the method for his patients.The bandages take a day
to harden.
1799 A visiting diplomat reports that he saw a Turkish patient treated by holding the injured limb in a box that was
then filled with plaster. He tried to interest European doctors in the method. The cast was big and heavy and
prevented ambulation.
1814 Pieter Hendricks uses plaster bandages—but the idea does not catch on.
1824 Dominique Larrey, Napoleon’s surgeon, uses egg white and lead powder.
1835 Louis Seutin: Starch bandages.
1852 Anthonius Mathijsen introduces plaster bandages in a medical book and has a friend who popularizes it. Soon,
large numbers of people are putting plaster into bandages. Until the 1950s, it was a job for medical students on
emergency call.Then machines led to commercial manufacture.
1903 Hoffa’s belief that “the plaster bandage will remain the essence of orthopedics for all time” seems to be going
the way of all predictions.
1970 to
present Development and widespread use of synthetic materials for casts.
Plaster did not enjoy universal popularity. Complete casts on fresh fractures can produce dreadful complications, and this
led some influential leaders to ban casts.Thomas and Jones in Britain and Knight, founder of the first residency program in
the United States, would have nothing to do with plaster. Knight fired one member of his staff for promoting its use.
Courtesy of Mercer Rang
or linen so that the resulting plaster dressing could be rolled onto the limb. This 55
tedious process of rubbing the plaster into the muslin or linen was done manu- General Principles of Cast Application
ally, just prior to application, by the surgeon or his assistant and continued until
about 50 years ago. Ready-to-use manufactured rolls of plaster of Paris were not
commonly available until the mid-20th century.
Plaster of Paris
Material Choices Plaster of Paris was named for
the large gypsum deposit in
Plaster of Paris has clearly been the standard material for cast construction over
the last 150 years. Recently, synthetic materials have evolved to the point of the Paris basin. Gypsum is
being practical and safe for cast immobilization of fractures. Exponential im- pulverized and heated to drive
provement in the texture, “rollability,” and “moldability” of synthetics has made off the water to form anhy-
them the cast material of choice for most modern orthopedic surgeons. Patients drous calcium sulfate. When
like them because they are lightweight and durable. We now use synthetics for water is added, the reaction
all pediatric orthopedic casts, except for serial corrective foot casts used to treat reverses.
clubfoot (Ponseti casts). However, some orthopedists still prefer the moldability
of traditional plaster for reducing and maintaining acute fractures.
Synthetic cast materials are more expensive than plaster of Paris; however, in
assessing overall cost one must consider the costs in time, labor, materials, and
repetitive visits to cast rooms by children who have inadvertently soaked or
damaged a plaster cast.

Duration of Treatment
The issue of when and for how long cast immobilization should be used for
fracture treatment has been historically controversial. Hugh Owen Thomas
(prolonged immobilization) and Lucas-Championniére (early motion) devel-
oped diametrically opposing views in the late 19th century (see Chapter 2). The
controversy remains but less for children’s fractures.

GENERAL PRINCIPLES OF CAST

APPLICATION
A B
A great variety of cast types are used in children (body jackets, hip spicas, ex-
tremity fracture casts), and we will not attempt to describe them all. Instead, Figure 5-2. Toe holding for leg casts. A) If
the focus will be on general principles of cast immobilization of extremity frac- the foot holder holds the first and second
toe, the foot will drift into undesired varus.
tures, including hip spica casts (Figs. 5-1, 5-2).
B) Holding the third and fourth toe with
Basic principles should be considered. For small children, you must decide the foot held in dorsiflexion ensures that
who can best hold the child’s arm or leg while the cast is applied. Although par- the foot will end up in a desirable position
ents can assist, most casts are better applied with a trained assistant holding the of slight dorsiflexion, valgus, and eversion.

A B C

Figure 5-1. A) A poorly molded long leg cast in a young child. Note that the foot is left in equinus, which makes sliding off more likely. Also
the heel is poorly molded. B) The cast was easily “slid” off in the clinic. C) The cast was entirely removed without splitting.These photographs
illustrate the very common practice of applying poorly fitting casts in children. Because of their activity level, children require snug, well-
molded casts.
56
Casts for Children’s Fractures
Figure 5-3. Excessive padding, often ap-
plied to prevent ulcerations, may actually
increase the chance for skin irritation. Any
advantage gained by excessive padding is
usually lost because it leads to a loose,
poorly fitting cast. The result is a cast that
allows excessive movement of the limb
(with potential for skin ulceration) or, in
severe cases, one that slides off the limb.
Figure 5-4. Felt at the junction (when the
cast is applied in two parts) makes the tran-
sition safer. Felt at the end of the cast (prox-
imal) makes it more comfortable.
Teutonic Diligence and
Plaster Casts
The philosophy of Fritz Lange, the famous late-19th-century German
surgeon, may be partially responsible for the many bulky, unsightly
casts seen today. Mayer noted: “A Lange plaster never broke for it was
applied with Teutonic thoroughness and reinforced at every joint. I
need say nothing of its weight and the difficulty his assistants had in
removing one of these massive creations.”
limb. Special foot-holding stands designed to keep the ankle at a neutral posi-
tion are useful for adolescents but are of little help in a young child.
Several steps increase your chances for a well-fitting cast. Whether or not
stockinette should be used on the skin prior to soft-roll application (Fig. 5-3)
depends on where and for what reason the cast is being applied. For elective
casts applied in an office or an outpatient clinic, use of stockinette decreases
“bunching” of soft-roll, allows a neat-appearing cast, stops the rough edge of
the cast from abrading the skin, and makes cast removal easier and perhaps safer
(less chance for cast-saw cuts or burns).
In postoperative casts applied in the operating room, the presence of surgical
dressings, suction drains, percutaneous pins, etc., makes stockinette use diffi-
cult. Also, with difficult manipulative reductions performed in the office or
clinic, application of stockinette is often an added step that impedes efficient,
rapid application and molding of the cast.
Other cast application accessories include using a layer of felt proximally in
the thigh, arm (humerus), or proximal calf. A 2- or 3-inch-wide band of felt
padding provides comfort and decreases skin irritation (Fig. 5-4). In spica casts
for thin children, we often use both (a) a complete layer of felt and (b) adhesive-
backed foam padding for bony prominences (iliac crest, greater trochanter, and
sacrum).
We advise that almost all casts applied in the operating room be immediately
split or univalved while the child is still anesthetized to decrease the discomfort,
aggravation, and fright involved in late-night cast splitting in the patient’s
room. This is particularly important in a children’s hospital, where multiple-pa-
tient rooms are common and where not only the patient and family but also
other patients and parents are present.
Rolling the Cast
Efficient rolling of the plaster or synthetic material requires experience. Appro-
priate rolling technique, including the placement of tucks to allow smooth
wrapping over a conical structure, is a slowly learned art. This is most impor-
tant for plaster casts in which the material will not stretch. Orthopedic residents
need instruction in this art, followed by supervised practice. Often their oppor-
tunities for learning are blunted by the current trend toward having orthopedic
technicians apply most casts in many training hospitals. The sad tradition of
lumpy, formless, inefficient casts applied at “Elsewhere General” continues, ap-
plied by inadequately trained surgeons or technicians.
Great care must be taken to avoid making casts too tight. This is a particular
problem with synthetic-material casts: They are often wrapped in the same
manner that one applies an elastic (Ace) bandage, with stretching to accommo-
date limb shape change rather than placing tucks. This is possible because the
underlying “cloth” is stretchable (in contrast to the muslin in plaster of Paris).
The result is a cast that is often too tight, particularly when applied in the oper-
ating room following surgery. In circumstances where any swelling whatsoever 57
is anticipated, synthetic cast materials should be applied with tucks, just as General Principles of Cast Application
would be done with ordinary plaster. This makes a less restrictive cast.
Casts in the operating room should be applied after the tourniquet has been
deflated to normalize limb volume. The cast is then applied, using the tuck
technique. Then in most cases, the cast should be immediately split to allow
further swelling, with the cast retightened 3-7 days later.

Cast Molding
Proper cast molding ensures good cast fit, thereby decreasing the chance for
cast sores (Fig. 5-5). A cast should fit the limb contours and be thought of in
the sculpting sense; that is, if the cast were removed and filled with plaster or
wax, the result would be a casting identical to the patient’s limb. Careful mold-
ing around bony prominences is required to achieve excellent fit. The calcaneus
is at great risk in the lower extremities; the molding must be focused on the soft
tissues above the tip of the calcaneus, leaving a recess for the heel prominence.
The concept of a well-molded cast contrasts with the terminology of applying A B
a “plaster dressing” after surgery. Many surgeons prefer a bulky “Robert Jones” Figure 5-5. A) Example of a thin, well-
dressing after surgery, followed by application of a well-molded cast once the molded cast applied to maintain reduction
swelling has subsided. We rarely do this in children because we can achieve the in a tibial fracture.The best casts have very
same effect by splitting and spreading the cast immediately postoperatively, with little padding; skin irritation is avoided by
careful contouring and molding. B) An ex-
later tightening. This avoids postoperative cast changes, which children detest.
tremely poorly molded cast. The posterior
border is relatively straight, predisposing to
Cast Ergonomics heel ulceration. Failure to use a posterior
splint has caused the anterior plaster to be
Cast edge trimming is time-consuming, but it can be avoided by careful plan- nearly an inch thick. This makes cast re-
ning when the cast material is rolled. For instance, at the distal end of a leg cast, moval difficult and dangerous. Plaster rolled
around a right angle requires asymmetric
application to have symmetrical thickness.

The Disappearing Toe

Skin Problems
Syndrome
The call is classic in children’s or-
thopedics—“My child’s toes are dis-
appearing.” Disappearing toes mean
the poorly fitted cast is allowing the
foot to pull up the cast. A skin ulcer
will soon follow. In this case, there
was an ulcer on the heel and on the
dorsum of the foot.

Early

At Follow-up
58
Casts for Children’s Fractures
Brandon Carrell
Brandon Carrell 1910–1982. Chief of
Staff at the Texas Scottish Rite Hospi-
tal, Dallas from 1945–1977. He empha-
sized the need for care in removing
casts in children and was a strong ad-
vocate of splitting (univalve or bivalve)
casts applied in the operating room.
“Although some insist on
‘always split to the skin’ or
‘always bivalve,’ we advise a
more refined approach...”
Figure 5-6. Spacers. A) Small commercially available spacers used for upper-extremity casts and for minimal spreading in lower-extremity
casts. B) A variety of larger, commercially available spacers useful for leg casts and hip spicas as well as for corrective wedging.
the plaster should be rolled at a 30° angle, keeping the lateral side short so that
subsequent trimming in the area of the fifth metatarsal head is not required. I
perhaps exaggerate by stating that no cast should ever end completely trans-
versely. Whether in the foot, the popliteal fossa, the groin, or the proximal
humeral area, casts predictably immobilize better, require less trimming, and fit
better if they end obliquely. Learning to wrap casts with oblique ends greatly
decreases the labor required to trim and finalize the cast. By avoiding trimming,
few sharp edges remain (a particular problem with synthetics).
CAST SPLITTING (BIVALVE, UNIVALVE)
Traditional training suggested that any cast requiring splitting be split com-
pletely to the skin, including the soft-roll. We have no argument with the “al-
ways split to the skin” philosophy for hospitals with little supervision of patients
casted following fracture reduction or operations. An edict issued by the “com-
manding officer” to split all casts to the skin is likely the best insurance against
cast complications, compartment syndromes, etc., in these circumstances. Also,
some orthopedists prefer a bivalve (double) split in all casts. With the use of
spacers to maintain the separation, we have been able to use single splits in most
cases—including synthetic casts (Fig. 5-6).
Although some insist on “always split to the skin” or “always bivalve,” we ad-
vise a more refined approach for a private hospital or office or in a high-quality
teaching hospital that provides close patient monitoring. This can be safe, eco-
nomical, and, most importantly, less distressing to children.
Synthetic-material casts require special methods because even though the cast
is split longitudinally (univalved), the resilience of the material will not allow the
cast to stay separated. Special commercially available spacers are needed.
Graded splitting of casts following fracture reduction or orthopedic opera-
tions requires good orthopedic judgment. Limited splitting can provide great
economic advantage to the hospital and surgeon without placing the patient at
increased risk. Our policy of graded splitting according to risk is as follows:
Level 1. Only modest swelling anticipated (e.g., following simple limb surgery
or reduction of simple distal radius fracture). Level 1 splitting includes a single
longitudinal split in the cast, combined with spreading and placing a spacer but
without cutting the underlying soft-roll. In our children’s hospital environment,
95% of cast splits are level 1. This percentage must be interpreted within the
context that we split nearly all postoperative casts and most fracture reduction
casts. Note that synthetic cast splits will not remain open unless spacers are
placed. Several manufacturers produce small plastic spacers of varying sizes that
are inserted to keep the cast separated. These are removed in 4-7 days after
swelling has subsided, with the cast then tightened with tape (upper limb) or
another roll of cast material (lower limb).
 59
TECHNIQUE TIPS: Cast Removal
Graded Cast Splitting According to Risk Severity

Level 1 Level 3

Level 2

Level 1. Cast split dorsally; soft-roll and underlying dressings not disturbed. For routine postoperative cases and simple
fractures. A spacer must be placed to hold the cast open.
Level 2. Both cast material and underlying soft-roll split to skin. For more serious cases of swelling.
Level 3. Cast split medially and laterally, with soft-roll cut down to skin. Allows removal of entire anterior half of cast for
inspection of skin and for palpation of compartments.

Level 2. For children with significant swelling anticipated (e.g., fracture with
potential for vascular problems; postoperative triple arthrodesis; other similar
cases). The single longitudinal split includes both the cast material and the un-
derlying soft-roll down to the skin, allowing wide spreading of the cast. Once
the soft-roll has been split, window edema can develop; therefore, thin strips of
soft-roll should be packed longitudinally into the split and should be over-
wrapped with a gauze bandage. A cast with a level 2 split can still be repaired A
(pulled together) once swelling has subsided, although care must be taken to
avoid “bunching” of the soft-roll (we rarely perform a level 2 split—most are
level 1, a few level 3).
Level 3. Used for cases with marked swelling anticipated (e.g., tibial fracture in
which compartment syndrome is suspected). This includes a medial and lateral
complete split of both the cast material and the underlying soft-roll down to the
skin. The anterior panel of the cast can then be removed for complete inspec-
tion of the limb and palpation of the compartments.

B
CAST REMOVAL
Figure 5-7. A) Stille cast shears. B) Use of
Cast removal problems are an important but under-emphasized topic in pedi- Stille cast shears to remove a short arm
cast. Developing skill with this instrument
atric orthopedics. Traditional cast shears can be used for small casts (Fig. 5-7).
allows you to avoid noisy cast saws when
Current cast-removal saws are loud, aggressive, somewhat dangerous, and terrify- removing certain casts. However, they
ing to children. No amount of conversation or playful application of the vibrat- work better for plaster than for synthetic
ing cast blade to one’s own hand to demonstrate that it “won’t cut” will placate a materials.
60
Casts for Children’s Fractures

Figure 5-8. Proper technique is required to

use a cast saw. Usually, the thumb is held against
the cast and the blade itself is pushed in an “up
and down” fashion against the cast material
without dragging the saw longitudinally.
Figure 5-9. Accessories required for
facile cast removal. Good scissors and a
spreader are key. A plaster shears may
allow removal of small casts without
using the cast saw.

properly suspicious child. More compact, quiet saws have recently become avail-
able but are suitable only for small extremity casts. They are hopelessly out-
matched by a hip spica.
Orthopedic technicians and orthopedists who deal with children can apply
many special techniques to minimize cast-removal trauma. Empathy is the first
step. All orthopedic residents and fellows should have a synthetic-material cast
applied on their own limb and then removed by a fellow resident (see how they
jump). This greatly increases sensitivity for the child’s plight. We do a cast ap-
plication-removal session with each new group of residents and fellows when
they rotate through our hospital.
The correct mechanics of cast-saw use must be mastered. They include plac-
ing the thumb and/or fingers on the cast as a stabilizing guide, with careful re-
ciprocal “up and down” movement (Fig. 5-8) rather than long dragging move-
ments of the blade along the cast that increase the risk for skin injury (cut or
burn). Avoid using the cast saw over bony prominences (medial malleolus, etc.)
and pull the cast away from the skin as you begin the cut.
Many accessory tools aid with separating the cast, cutting the soft-roll, and
getting the cast off (Fig. 5-9). Sophisticated plaster shears allow cast removal in
children without use of a saw. Those made by Stille (Sweden) are particularly
effective for removing clubfoot and other small casts. Orthopedists trained in
the modern era are sometimes unaware of these special plaster shears that allow
quiet, safe, cast removal.

UPPER EXTREMITY CASTS

Most of the principles that will be presented in the lower extremity section apply
here. Application techniques are similar to those used for adults. We routinely use
synthetic casts, even following acute fracture reduction. The cast is split immedi-
ately, with a spacer placed to hold the cast open until swelling subsides.

Figure 5-10. Poor-quality, poorly molded
long arm cast. Note the space at the tip of
the olecranon. Also note the thickness an-
teriorly in the antecubital fossa area. Re-
duction has been lost.
Application Principles
Precise three-point forearm molding technique is required both to maintain
fracture reduction and to keep the cast from sliding off (Fig. 5-10). If only rolls
of plaster are applied, the cast becomes excessively thick anteriorly at the elbow
(antecubital area) and too thin over the olecranon. Charnley, in his classic frac-
ture text, noted that if plaster is wrapped uniformly around a right angle, the 61
cast will be four times as thick in the concavity as on the convexity. Upper Extremity Casts
Excess soft-roll and plaster in the concavity makes a cast ugly and increases
the chance that it will slide off. We avoid this by using splints posteriorly over
the olecranon area or by asymmetrically rolling the cast material with a back-
and-forth motion over the convexity (olecranon) to minimize thickness anteri-
orly. Careful molding is then performed in the antecubital area to produce a
beveled right angle. A properly applied long arm cast has a geometrically crisp
look with (a) a sharp 90° (right) angle anteriorly in the antecubital fossa and (b)
a sharp right angle posteriorly produced by a straight border molded along the
ulna and humerus (Fig. 5-11). Such a cast is extremely unlikely to slide down or
fall off, avoiding the shopping bag cast syndrome (mother brings the cast back
in a shopping bag). “Show me your plaster and
I’ll show you what kind of
Forearm Molding orthopedist you are”
For reduction of forearm and wrist fractures, you will need to decide if you can
apply a long arm (above-elbow) cast in a single phase or whether you will better
hold the reduction and mold the cast if it is applied in two stages (first short
arm, then extend to above elbow). In most circumstances, the latter is preferred.
The junction must be carefully padded to avoid skin injury.

Figure 5-11. A properly applied long arm

cast has a geometrically crisp look. A) The
x-ray shows a sharp right angle anteriorly
in the antecubital fossa. B) The ulnar bor-
der is straight as is the posterior humeral
border.

Charnley, in his classic text, emphasized

proper casting techniques: three-point mold-
(Source: Charnley J. The closed treatment of common fractures. Edinburgh, Livingstone, ing is used to maintain reduction of fractures,
1980. [Figures reproduced with permission]) and asymmetric plaster application avoids ex-
cess cast thickness in the concavity of joints.
62
Casts for Children’s Fractures
TECHNIQUE TIPS:
Application of a Long Arm Cast to Reduce and
Maintain an Unstable Distal Radius Fracture—
Two-Stage Technique

Felt

1 2

After reduction, padding is applied Synthetic cast applied—three-point

with the wrist ulnarly deviated and molding.
flexed—the circumferential felt allows
safe extension of the cast.

3 4

This cast is then extended above the The final product—a cast of beauty
elbow. and reliability.
 Applying a cast to the forearm first and then extending it (elbow bent to 90°) Antecubital Skin Ulcer Problems
carries a risk of producing a severe skin ulcer if the sharp proximal edge of the
cast gouges into the antecubital fossa. A similar complication can occur if the
entire cast is applied at once but in too little elbow flexion. As the cast sets, the
elbow is “adjusted” to 90° with an ulcerogenic antecubital ridge produced (Fig.
5-12).
Hyndman et al. emphasized the need for careful forearm molding to main-
tain a reduction. The ratio of cast height to width as well as three-point mold-
ing are critical (Fig 5-13). If you get very good at this, you may be able to keep
a distal radius fracture reduced with a short arm cast only, whereas others may
need a long arm cast.
The final effect should be a cast that is thin, aesthetic, and biomechani-
cally sound. Calot, the famous 19th-century French surgeon, stated: “Show
me your plaster and I’ll show you what kind of orthopaedist you are.”
We concur. I make a hobby of observing casts (in shopping malls, in restau- A B
rants, or on relatives of children in clinic) that have been applied by others,
guessing who applied the cast (orthopedist, orthopedic technician, family Figure 5-12. A) Long arm cast applied in
a single phase, elbow flexed to 90˚ after
practitioner, other). A well-trained orthopedist should apply functional, fiberglass was applied. B) Long arm cast ap-
aesthetic casts that demonstrate a leadership role in caring for musculoskele- plied in a single phase with the elbow
tal problems. flexed after the padding was applied. The
angle cannot be changed after application
of any of the cast materials.
Errors—Cast Too Short
Many people make their casts too short proximally. The long arm cast seen in Figure
5-14 was far too short (to just above the elbow) and reduction was lost despite pin-
ning.

Conversion to Short Arm?

I rarely convert a long arm cast to a short arm cast simply to give the child early
elbow motion. The cost of cast removal and placement of a new cast, particu-
larly if synthetic materials and expensive labor are required (i.e., you or the cast
technician), is prohibitive. Reimbursement is unpredictable. Also, children do
not like their cast removed with a cast saw, as noted previously. For these rea- Figure 5-14. Cast too short. This child
had a supracondylar fracture that was
sons, in almost all long arm casts, we have the child wear the original cast until pinned anatomically but presented to us
the fracture is healed (often 6 weeks). with loss of reduction, despite the pins.
Her mini-cast is partially responsible, ex-
tending only a few centimeters above the
fracture line.

Figure 5-13. Hyndman’s cast ratio. In his now classic paper, Hyndman noted that one needs not only a three-point
mold but also a cast that is thin from top to bottom (as compared to width). The x-rays and cast shown here
demonstrate this point.
63
64
Casts for Children’s Fractures
A B
Figure 5-15. Clearly the biomechanics of
fractures and their overlying muscles must
be understood when applying casts. For
example, in the so-called Gillespie fracture,
if the foot is brought up to neutral position
for casting, the distal tibial fracture will an-
gulate (recurvatum) (Figure A). In this rare
instance, the foot should be purposely
casted in equinus (Figure B).
LOWER EXTREMITY CASTS
Principles—The cast should be molded with the foot in neutral position to
avoid the development of equinus in the cast. Also, three-point molding and
foot position help to maintain fracture reduction (Fig 5-15). To make a well-
molded ankle joint, with the plaster thicker on the heel than anteriorly, a splint
can be applied over the heel. Otherwise, as Charnley noted, the anterior area
will be many times thicker than the heel (you will want to split the cast anteri-
orly, it should be thin here).
An ideal cast should be molded to demonstrate the calcaneal prominence and
the malleoli. It is impossible to overemphasize the need for proper molding
around the calcaneus, the most common area for skin irritation and ulceration in
children’s casts (Fig. 5-16). The depth of the sculpted inset above the calcaneus
may need to be up to 2 cm, depending on the size of the child, to avoid pressure
on the calcaneus (Fig. 5-17). Examining a basketball shoe demonstrates that
manufacturers recognize the need for a deep recess for the heel, with a supportive
“counter” above. With final heel molding, you should feel that the calcaneus is
nested in a deeply molded “cup” that you have shaped. A cast with a straight pos-
terior calf segment is much more likely to produce heel ulceration.
Similarly, the arch of the foot should be molded with a recess in the cast for
the metatarsal heads. There is no place for a board or other rigid flat structure in
molding the bottom of a cast. The modern cast should have a bottom shaped
like the insole of a well-designed jogging shoe. With excellent molding, less cast
padding is needed and the cast is less likely to slide off.
A B C
Figure 5-16. Molding around the calcaneus. A) With final molding, the tip of the calcaneus is
palpated in the palm of your hand.There should be a deep cup in the cast at this area so that
any pressure is taken on the soft tissues above the calcaneus rather than at the tip of the bone.
B) The final product. C) A so-called stove pipe cast with a straight posterior border.This child is
very likely to get a heel ulcer.The posterior border of a leg cast should never be straight. D) A
properly molded long leg cast—note molded areas above ankle and behind knee.
 65
Lower Extremity Casts

Figure 5-17. The ideal mold (lateral view) for a

short leg cast. Note the beautiful relatively deep, but
smooth, mold well above the calcaneous. This pre-
vents heel ulcers. The area anterior to the ankle is Figure 5-18. It requires experience and careful observation to avoid creating defor-
very thin. mity with cast application.This fracture was made worse by the cast.

Long Leg Casts

A long leg cast requires careful molding about the knee with the knee kept at
10°-15° flexion to avoid posterior capsule strain. The decision regarding a long
leg cast in one or two segments depends on the circumstances.

Sequence—Long Leg Cast for Tibial Fracture

For most tibial fractures that require reduction and casting, the cast is best ap-
plied in two segments, particularly in a larger child. Allow gravity to be your
friend by applying and molding the below knee segment with the knee bent
over the edge of the table (tibia vertical). The cast can then be extended for the
above knee segment with the patient supine. Be very careful as the cast hardens
to carefully attend to knee angle to avoid “late-stage hardening” buckles.

Creating Deformity with Casts

Each year we see fractures that come in with near anatomic alignment and after
casting appear malreduced (Fig. 5-18). It requires experience and careful obser-
vation to avoid creating deformity with cast application, particularly in the tibia.
The leg (calf ) section is best applied first, with the leg in a vertical position to
allow gravity to help as you mold the tibia section. Then after placing a circum-
ferencial felt band at the junction, the cast is converted to a long leg type.

Casts Applied in the Operating Room

Postoperative casts are particularly difficult to apply safely and correctly (Fig. 5-
19). The surgical dressing should be thin to allow good cast fit. We commonly
use suction drainage when bleeding is anticipated, rather than using a thick Figure 5-19. A) The assistant cannot be
compressive dressing that leads to poor cast fitting. daydreaming when the cast is setting. If he
Many surgeons prefer a bulky type of cast, a posterior and anterior splint, or does not pay rapt attention, the child is
likely to develop a buckle in the plaster at
even a Robert Jones bulky dressing following surgery, with the cast applied later. the knee level.This is particularly a feature
Again, sensitivity for the child and economics should be considered. If every of synthetic casts. B) Buckle in cast in knee
child that you operate on requires a return for a complete cast change within a area. Such buckles are ulcerogenic.
66 TECHNIQUE TIPS:
Casts for Children’s Fractures Two-Stage Application of a Long Leg (Above Knee) Cast
(for reduction of tibia fracture in a larger patient—ensures that tibial
segment, foot, and ankle are molded perfectly—then extended to proximal thigh)

1) Leg vertical – padding applied plus 2) Synthetic material applied. 3) Splint over heel to make back
circular felt at junction. thicker than front.

4) Very careful molding to contour 5) Circular felt to protect proximal 6) Padding extended plus apply felt in
of calcaneus—maintain fracture thigh. groin (for comfort).
reduction.

7) Patient now supine. Extend cast- 8) Molding long leg cast. 9) The final product. A few degrees
splint over knee to strengthen. less knee flexion might be better for
subsequent walking.
week after surgery, the expense becomes significant. Also as already noted, chil- 67
dren hate cast changes. Cast Wedging

Posterior Splints in Children

Posterior splints, made of plaster or synthetics, are often used safely in adults as a
temporary form of immobilization. Their use in children (especially in those
younger than 5 years) is risky because they almost routinely pull their heel out of
its intended spot, with a high risk for developing a heel ulcer (Fig. 5-20). Many
“Wedging techniques should
experts advise that children younger than 6 years not be immobilized with a pos-
terior splint. A cast is safer because it holds the ankle in its correct position. be mastered by orthopaedists
who care for children, since
CAST WEDGING angular alignment is often
Careful planning and implementation of cast “wedges” to correct angular defor- all that is required for
mity can simplify the management of lower-extremity fractures in children. In
the lower extremity, wedging can be used for femoral fractures (hip spica acceptable position and
wedged—Fig. 5-21) as well as for tibial fractures. The correction is almost fracture healing.”

Figure 5-20. A) Posterior splints are risky for use

in young children because they routinely pull out of
them, resulting in a risk for heel ulcer. B) Lateral x-
ray of a child placed in a splint to temporarily im-
mobilize for a distal tibial fracture. The child has
pulled out of the splint and is a risk for developing a
heel ulcer. If they are used, it should only be for a
A day or two. Better to use an anterior plus posterior
B
splint or a temporary cast.

Spica Cast Medial Open Wedge + Spacer

Before Wedge After Wedge Final

Figure 5-21. Young child with femur fracture that is drifting into varus angula-
tion at the fracture site can be improved by wedging of the cast. Skill and experi-
ence are required to wedge casts safely.
 NOTE: Cast wedging requires skill and experience to avoid skin problems.

Look at cast and x-ray to- Marking cast. (Cast had been uni- Hinge marked opposite side
gether. Determine level of valved, this is a follow-up visit). where cast will be opened.
fracture angulation (where
you wish to correct).

Before Wedge After Wedge

always an opening wedge formed by making a circular cut in the cast at the level
of deformity, leaving about 1 cm of the cast uncut as a fulcrum. The cast is then
levered open on the opposite side to correct the deformity. Care must be taken
to make a smooth bend to avoid skin necrosis. Inspect the x-ray for a possible
ridge, keep the patient around for 30 minutes to be sure the “post-wedge ache”
subsides, and warn the patient to return if there is late pain.
Appropriate spacers are placed in the wedge, with image intensifier or x-ray
views taken with the spacer temporarily taped in position. When the correction
is adequate, the wedge and spacer are incorporated into the cast to maintain the
new position. Artful cast room wedging has allowed us to avoid taking literally
hundreds of children with loss of angular correction in femoral and tibial frac-
tures back to the operating room.
Even in upper extremity fractures, opening wedges can be used to correct an
angular deformity or “sag” in the mid-forearm following a bone fracture, some-
times avoiding re-manipulation and cast change under anesthesia. Wedging
techniques should be mastered by orthopedists who care for children, because
angular alignment is often all that is required for acceptable position and frac-
ture healing.

68
HIP SPICA CASTS FOR FEMUR 69
FRACTURES Cast Complications

A spica cast is the mainstay for treatment of femoral fractures in children. The
use of femoral fracture hip spica casts can range from use in a 7-month-old
victim of child abuse to an 8-year-old with a spiral midshaft fracture. Many
variations of spica can be used, ranging from a simple one-and-one-half spica
with the femur relatively extended to a complex, near 90°-90° hip-knee posi-
tion to control shortening. We will present a few principles, focusing on a
method that only moderately flexes the hip and knee. The more radical hip-
knee flexion casts (so-called 90-90) can be used; however, because of increas-
ingly common reports of nerve injury, skin slough, or calf compartment syn-
drome associated with their use, Frick has diminished our enthusiasm for the
90°-90° position (Fig. 5-22).
We use synthetic-material casts in all age groups because they are easier to
apply, easier to wedge, and easier to maintain. For a child younger than the age
of 2 years, with a simple oblique fracture of the femur, we will apply an early
spica, usually without general anesthesia. If the fracture is a nondisplaced spiral
fracture (the most common type at this age), a single hip spica can be used,
making diapering and bathing easier.
In children aged 2-6 years, we sometimes place the children in skin traction
for 24 or 48 hours, particularly if there are associated injuries. We then apply the
hip spica with the child anesthetized. This variation of the early spica allows time
for proper assessment of the child and to find a civilized operating-room time.
Thus in our hospital the term “immediate spica” has been replaced with “early
spica” and implies cast application within a few days of injury at a time that is
safe and convenient for all parties. These children have a light general anesthesia
with a one-and-one-half hip spica cast applied. Use of an image intensifier to
confirm fracture position in the operating room (just prior to spica application)
decreases the need for subsequent cast wedging. An immediate post-spica-appli- Figure 5-22. The risks in using a 90°-90°
cation image intensifier view confirms the position, and, if wedge correction is cast includes junctional problems (if trac-
required, it is done immediately while the child is still anesthetized. tion applied to the leg cast, which is applied
first. Reported problems include skin
necrosis (behind knee), compartment syn-
CAST COMPLICATIONS drome (calf), and anterior skin loss (distal
calf).
All orthopedic surgeons are aware of the many complications related to cast im-
mobilization. Some families do not understand cast care instructions but more
often the child is uncooperative or not properly supervised. The resulting wet
casts, damaged casts, destroyed casts, etc., are common to all age groups and
will not be specifically addressed here. We emphasize, however, the importance
of the orthopedic technician and/or surgeon giving the family a handout detail-
ing cast care as well as providing clear and simple instructions.

The Veterinary Approach—Understanding

Your Client
A perhaps slightly jaded, yet practical, approach to childhood behavior is to use
what we call the veterinary approach when using a cast for an unstable lower
limb (tibial, ankle) fracture. With certain families, rather than relying on in-
structions and handouts alone, we assume that they will not get the message
(puppies do not read their “handouts”). Instead, we create a cast that keeps
them from creating a problem. For example, in an unstable distal tibial (or me-
dial malleolar) fracture, the cast would be a long leg type with the knee flexed to
70
Casts for Children’s Fractures TECHNIQUE TIPS:
Application of a Hip Spica for Child with
Femur Fracture
(Cast in relative extension minimizes risk to skin and compartments)

1) Short leg (below knee segment)
applied first.To help hold the limb. Lit-
tle traction or pressure can be used
and the junction must be well padded
(we use felt). (Many experts do not
incorporate the foot and apply the
calf segment last.)
2) Limb positioned in relative exten-
sion. Cast padding added. Note tem-
porary spacers under padding over
abdomen (use towels or skin tape
packs).
3) Synthetic material rolled on. Again
note cast prominence over temporary
abdominal protection spacers.

4) Spica completed. 5) View from above—cast complete— 6) Spica cast complete abdominal
note cast has been trimmed down to pads removed. Wood is attached to
the umbilicus level to ensure easy ab- opposite thigh for stability.
dominal expansion and breathing—
The temporary pads will be removed
once cast hardens.

Pre-Spica film After Spica

NOTE:We have changed to this more relaxed position, as compared to the 90‚-90˚ po-
sition, which has a risk for skin and compartment problems in the calf. Some would not
apply the calf segment first, nor incorporate the foot, to further minimize these risks.
90° (right angle) for the first 4 weeks. This position prevents weight-bearing, 71
even in uncooperative patients or those who lack understanding. Cast Complications

Showering and Bathing

The issue of showering and bathing with a cast on remains controversial, even
with synthetic-material casts. Children and adolescents seem to do poorly with
the commonly prescribed method of taping a plastic bag over an upper- or
lower-extremity cast for showering. The method commonly fails, leading to a
wet cast that must be replaced—a process whose true cost may be several hun-
dred dollars. Instead of showers, we suggest that the limb not be covered with
any special plastic and that the child be bathed in a tub with the arm or leg cast
left on the edge of the tub. A parent must be present to help the younger child
with bathing.
On the other hand, newer types of special “shower in your cast” protective
devices are coming on the market and may be considered. Issues, such as how
well the patient applies the device (they often leak) and who pays for the new
cast when they fail, remain.
Use of Gore-Tex cast material to produce a so-called swimming cast has
gained popularity but has problems also (hard to mold for acute fracture reduc-
tion, expense—takes more time to apply and remove). The Gore-Tex option is
a good one if your patient has the extra money for additional materials and
technician time.

Foreign Bodies Under Casts

Cast instructions should emphasize that nothing be placed inside the cast. The
need to scratch under a cast is common, with devices such as coat hangers or
other sharp objects inserted for relief. Serious skin excoriation can result.
Despite your instructions, children will deposit all sorts of items under their
cast either purposely or inadvertently (Figs. 5-23, 5-24). If a child complains of
pain under a cast, you must be prepared to window or even remove the cast to
evaluate for possible skin ulceration, which can be produced by foreign bodies
under the cast.

Figure 5-24. This child never complained

of pain after surgery. Six weeks later, a sig-
nificant ulceration produced by a hair bar-
Figure 5-23. This child returned to clinic after 4 weeks in a short leg walking cast. A toy cog rette was noted. Apparently, the child had
was found stuck to his skin. dropped it into the cast.
72
Casts for Children’s Fractures
Figure 5-25. Typical old heel ulcer over
the calcaneus in a patient who had a
poorly applied long let cast.
Figure 5-27. Ulceration with skin loss
over the metatarsal heads in a child
treated for fixed equinus. Postoperative
casting with forced dorsiflexion led to this
ulceration. The child never complained be-
cause he had a neurologic disorder.
A B
Figure 5-26. Dorsal ulceration.A) Small ulceration in the area where anterior soft-roll and
casting material was bunched. Likely the cast was further dorsiflexed after the casting materi-
als had been applied, producing an ulcer. B) A more severe form of the same problem. The
child sloughed the entire dorsum of the foot.
Cast Ulcers Due to Poor Cast Design
Many cast problems are the result of inattention to detail by the applying sur-
geon or technician. Ulceration over the tip of calcaneus is the most common
skin problem associated with leg casts (Fig. 5-25). Heel ulcers can be almost en-
tirely avoided by understanding the normal contour and shape of the calcaneus
and by careful cast molding about the calcaneus. Leg casts with an entirely
straight posterior border are a set-up for heel ulceration. When detected, they
should be corrected before skin ulceration develops. William T. Green, the
famed Boston Children’s Hospital surgeon, marked poorly applied casts with a
black marker, an indication that they had to be changed before the sun had set.
Improperly applied leg casts can cause other types of skin ulceration. If the
foot is left in equinus when the soft-roll and/or plaster is applied, with the foot
subsequently dorsiflexed, the resulting dorsiflexion ridge in the cast anterior to
the ankle will cause predictable skin ulceration. The entire dorsum of the foot
can slough (Fig. 5-26).
Similarly, excessive pressure on the bottom of the foot can produce ulcerations
over the metatarsal heads (Fig. 5-27). Careful molding of a metatarsal recess to
accommodate the metatarsal heads is required to avoid this complication.
The juncture between the leg and thigh segments of a long leg cast that has
been constructed sequentially (leg first, then thigh) is a common source of skin
ulceration. If the posterior segment of the leg cast is left too long, with the knee
then flexed to apply the thigh segment, the resulting ridge can produce a full-
thickness ulceration in the hamstring area.
Unfortunately, children commonly do not experience any prolonged sense of
pain when an improperly applied cast is producing skin ulcerations. It hurts
only until the skin becomes numb and then stops. In many cases, you may not
detect ulcerations or skin injury until the time of planned cast removal. It is
thus imperative that orthopedists who treat children learn to apply postopera-
tive casts that are extremely unlikely to produce skin pressure. Pressure of 30
mm Hg over 3 hours will produce skin necrosis.
 73
Suggested Readings

The Dorsiflexion “Crinkle”

This illustration for Albee’s classic 1919 text Orthopedic and soft-roll and/or plaster often causes pain and sometimes
Reconstruction Surgery demonstrates the problems associ- causes ulceration.This is avoided by holding the foot dorsi-
ated with dorsiflexing the foot after any material has been flexed before any materials are applied.
applied, either soft-roll or plaster.The dorsal bunching of the

Suggested Readings
Blount WP. Fractures in children. Baltimore:
Williams & Wilkins, 1955.
Charnley J. The closed treatment of com-
mon fractures. Edinburgh: B & S Living-
stone, 1950.
Chess DG, Hyndman JC, Leahey JL, Brown
DCS, Sinclair AM: Short arm plaster
cast for distal pediatric forearm fractures.
J Ped Orthop 1994;14:211-213.
Czertak DJ, Hennrikus WL. The treatment
of pediatric femur fractures with early 90-
90 spica casting. J Pediatr Orthop. 1999
Mar-Apr;19(2):229-32.
Large TM, Frick SL. Compartment syn- Wenger D, Rang M: Casts in Children in the
drome of the leg after treatment of a Art and Practice of Children’s Orthope-
femoral fracture with an early sitting dics, Raven Press, 1993 (now Lippincott
spica cast. A report of two cases. J Bone Williams & Wilkins).
Joint Surg Am. 2003 Nov;85-A(11): Wu KK. Techniques in surgical casting and
2207-10. splinting. Philadelphia: Lea & Febiger,
Wehbe, A: Plaster Uses and Misuses, Clinn 1987.
Orthop. 167:242-249, 1982.
Weiss A et al. Peroneal nerve palsy after early
cast application for femoral fractures in
children. J Pediatr Orthop. 1992 Jan;
12(1):25-8.
 Clavicle
6
Maya Pring m Dennis Wenger

• Assessing the Patient 76

• Radiographic Issues 77
• Classification 77
• Treatment
—Type I 79
—Type II 80
—Type III 80
—Special Fractures 82
• Problems 82

INTRODUCTION
Sir Robert Peel, Prime Minister of Britain in 1834, would have been among the
“Don’t touch the
first to agree that the clavicle is a fragile bone. In 1850, he died after falling
from his horse on Constitution Hill, having sustained a fracture of the clavicle,
patient—state first
which probably penetrated the subclavian vessels. what you see”
The unique design of the clavicle allows dexterity and sophisticated use of
the complex upper limb and serves as the only true skeletal attachment of the —OSLER
humerus and scapula to the axial skeleton. The small size of the clavicle and its
relative fragility allow incredible dexterity but put it at risk for fracture, espe-
cially when bipeds suddenly become quadrupeds (falling down). Of course,
children have such mishaps everyday; thus clavicle fractures are among the most
common injuries in children.
Looking from above, the clavicle has an S shape from the sternum medially
to the acromion laterally. In cross section, it changes from a round or prismatic

75
76
Clavicle
“The small size of the
clavicle and its relative
fragility allow incredible
dexterity but puts it at risk
for fracture”
shape medially to a flattened shape along the lateral third, and when viewed
from the front, it appears flat and straight (Fig. 6-1).
The unique double curve of the clavicle allows for motion of the shoulder in
all directions and acts as a fulcrum to improve the effectiveness of the muscles
that move the arm. The clavicle helps to suspend the upper extremity from the
thorax while protecting the subclavian vessels beneath it. The deltoid, pectoralis
major, and subclavius all have a significant portion of their origin on the clavi-
cle; the sternocleidomastoid and trapezius insert onto this small bone.
The vast majority of pediatric clavicle fractures can be treated conserva-
tively; however, one must recognize the rare fracture that requires surgical inter-
vention as well as the very rare clavicle fracture that may be life threatening.

ASSESSING THE PATIENT

Infancy
Clavicle fractures are one of the most common injuries sustained during birth;
children of large birth weight (! 4,000g) and those with shoulder dystocia are
at the highest risk. Infants who sustain a clavicle fracture may also sustain a
brachial plexus injury due to nerve stretch (Erb’s palsy). The neonate with a
clavicle fracture may present with an asymmetric Moro reflex or an apparently
flail upper extremity.
Differentiating a neurologic injury from a clavicle fracture during the first
few weeks of life can be extremely difficult, and the child may have both. X-ray
or ultrasound can diagnose the fracture, but clear neurologic assessment of the
upper extremity may not be possible until the fracture has healed.

Lateral Medial Children and Adolescents

AP view
Failure to palpate the fractured clavicle frequently leads to incorrect diagnosis
(i.e., shoulder strain or AC separation). However, because the clavicle is subcu-
taneous for most of its length, fractures should be easy to identify in the older
child and adolescent with a good physical exam. Clinical deformity, ecchymo-
sis, swelling (Fig. 6-2) and point tenderness lead the physician to the diagnosis.
Because of its subcutaneous nature, clavicle fractures can tent and erode

Superior view
Trapezius
Sterno-cleido-
mastoid
Deltoid
Ernst Moro (1874–1951)
Pectoralis Major
German pediatrician born December 8,
1874 described a defensive reflex seen in
the first 6 months of life. In response to a
Inferior view loud noise, an infant draws its arms across
the chest in an embracing manner. An
Pectoralis Major asymmetric Moro reflex may be second-
ary to neurologic injury or fracture.

Subclavius

Figure 6-1. Anatomy of the clavicle.

through the skin if severely angulated. Carefully assess the fracture site so closed 77
fractures do not become open fractures. Classification
Limb-threatening concerns associated with clavicle fractures and dislocations
that need to be identified immediately include vascular injury (subclavian ves-
sels), neurologic injury (brachial plexus), and injury to the mediastinal struc-
tures (esophagus, trachea, pleura, lung) by angulated or displaced fragments.

RADIOGRAPHIC ISSUES
One of the first bones to ossify during the early weeks of gestation, the clavicle
has three centers of ossification. There are two primary centers for the body
(medial and a lateral), which appear during the fifth or sixth week of fetal life,
and a secondary center for the sternal (medial) end, which appears in late
teenage years. The shaft can be radiographically identified at birth; however, the
medial epiphysis appears in the teenage years and does not fuse to the shaft of
the clavicle until the early twenties. Salter-Harris fractures through the physis
are often mistaken for medial clavicle dislocations in adolescents.
Figure 6-2. The clavicle is subcutaneous
Almost all clavicle fractures can be adequately identified with a single AP
making deformity noticeable. This patient
view (Fig. 6-2). Problem fractures may require special views. The orientation has a healing left clavicle fracture (healing
of the clavicle makes it difficult to get two x-ray views at 90° to each other. in bayonet apposition). Patients need to be
Even with additional views, the medial portion of the clavicle is difficult to told about the size of callus that will ap-
see because of the sternum and mediastinum. In addition to a straight AP pear (and later resorb).
view of the clavicle, an apical lordotic x-ray can help visualize the medial clav-
icle without overlap of the sternum (see Table 6-1). Any question about the At Injury
nature of a clavicular injury should be futher investigated with a CT scan,
which allows the best visualization of the clavicle. Concern for vascular injury
mandates an arteriogram. A
2 Weeks Later
CLASSIFICATION
Fractures can be complete, or the clavicle can be plastically deformed with a
greenstick type of fracture (Fig 6-3). The very thick layer of periosteum surround-
ing the pediatric clavicle tends to maintain the alignment of the fracture, which B
typically leads to early union in infants and children. As children become Figure 6-3. A) Greenstick clavicle frac-
teenagers, the periosteum no longer acts as a strong supporting structure and non- ture as frequently seen in young children.
union becomes more common—especially in vigorous athletes and laborers. B) Healing with abundant callus.

Table 6-1 Radiographic Assessment of Clavicle Injuries

AP View Apical Lordotic

Allows good visualization of the superior/inferior Allows better visualization of the medial clavicles without
displacement of shaft fractures overlap of the sternum

Standard AP Tube angled 40°–45°

 Classification of Pediatric Clavicle Fractures

Type 1: Shaft fractures typically have shortening and supe-

Basic types of clavicle fractures rior angulation.

Type 2: Distal fractures (further subdivided by Dameron and Rockwood).

Note:The epiphysis and periosteum typically remain in place and the shaft displaces.

I Sprain of AC ligaments only II Widening of AC joint III Superior displacement 25-100%

IV Posterior displacement V Superior displacement >100% VI Inferior displacement

Type 3: Subdivision of medial clavicle fractures. The description of the fracture can be based on displacement of the
shaft—anterior, posterior, superior, or inferior.

A. Physeal fracture B. Sternoclavicular dislocation (rare) C. Medial shaft fracture

78
 The basic types of fracture include medial, lateral, and shaft fractures. Medial 79
and lateral fractures have been further subdivided based on location of the frac- Treatment
ture and displacement of the shaft. (We believe that clavicle fractures have been
overclassified in the literature. See “Classification of Pediatric Clavicle Frac-
tures” for an overview of the subclassifications.)

TREATMENT

Shaft Fractures (Type 1)

Infant
Infant clavicular fractures can be treated by pinning the shirt sleeve to the shirt
or elastic bandage wrapping the arm to the body for 2-3 weeks (Fig 6-4). This
Figure 6-4. An infant with a clavicle frac-
treatment provides some immoblization and pain relief and reminds people not ture can be treated by pinning the sleeve
to pick the baby up by the arm. Infantile fractures tend to heal well regardless of (of the injured side) to the body of the gar-
treatment. The associated injuries including brachial plexus palsy require more ment. A second option (illustrated here):
focused attention; however, these are difficult to evaluate until the fracture heals wrap the limb to the trunk gently with an
and motion can be better assessed. ace bandage.

Children and Adolescents

It has been said that “if the two ends of the clavicle are in the same room they
will heal and remodel adequately.” Thus the typical case generally recieves little
attention. The exception would be a fracture that severly tents the skin or risks
the neurovascular bundle underneath.
A sling can be used for minimally displaced fractures. Many advocate a fig-
ure-of-8 brace to gently pull the shoulders back so as to minimize overlap of the
fracture fragments; however, the pad of the brace must be soft to avoid undue
pressure on a midshaft fracture, making the brace difficult to wear (see Table 6-2
and Fig. 6-5). In cases that are not markedly shortened, an imaginative ap-
proach is to provide both a sling and figure-of-8 brace to manage the fracture

Table 6-2 Classic Dilemma—Sling vs. Figure-of-8 Brace

Advantages Disadvantages
SLING
Very inexpensive No ability to pull
fracture to length
Easy to put on
Hand is not free
No pressure over fracture

A few sizes fit all

FIGURE-OF-8
Can hold fracture better Harder to put on
reduced (in theory)
Focal pressure over
Hands free for activities fracture site
Figure 6-5. Perhaps the easiest way to
Need to keep multiple apply a snug figure-of-8 brace without
sizes in stock tears. Although commercial braces are
available, a stockinet filled with cast
padding and secured by two saftey pins can
Photos courtesy of C. Farnsworth
be used in a pinch.
80
Clavicle
At Injury
A Protect the fracture for 3 weeks, with contact sports avoided for another 3
3 Months Later
B sess for motion at the fracture site. One pushes on the medial or lateral segment to
Figure 6-7. A) Significantly displaced and
comminuted fracture in a teenager. B)
Three months later—note remodeling
“Almost all medial clavicle
fracture in patients under
age 18 years appear to be
sternoclavicluar dislocations
but in fact are transphyseal
injuries”
Anterior
Posterior
Figure 6-8. Type 3A medial clavicle frac-
ture with posterior displacement.
Figure 6-6. We warn parents that the resulting callus from a clavicle fracture may be the
size of a walnut (or even an egg in a teenager).
symptomatically. The patient can use both initially (first 3-4 days when pain is
greatest) and then one or the other according to which is most comfortable.
weeks. As in most simple injuries, half the treatment consists of educating the
parents about the normal course: An unsightly lump will appear with fracture
healing (callus) and will persist for at least a year while remodeling progresses
(we tell parents that the lump may be the size of a walnut or an egg—Fig. 6-6).
Although x-rays of a fracture healing in bayonet opposistion may frighten the
parents, studies have shown that a significant amount of angulation and overlap
can be accepted (Fig 6-7).
How should these patients be followed? Palpate the clavicle at each exam to as-
be sure the clavicle moves as a unit. Once the fracture is stable and non tender, the
patient may slowly return to sports. Final x-rays are usually obtained at 6 weeks; if
there are indications for nonunion, longer follow-up becomes necessary.
Lateral Fractures (Type 2)
Dameron and Rockwood suggest that type I, II, and III injuries will heal and
remodel without intervention. Reduction and fixation of distal clavicle injuries
is only necessary for types IV, V, and VI that have a severe and fixed deformity.
Distal clavicle fractures in pediatric patients are usually trans-physeal and not
true AC separations (as seen in adults). The intact periosteum allows children to
heal and remodel with few complications without operative intervention.
Most lateral clavicle fractures are adequately treated with a sling or figure-of-
8 brace for 3 weeks followed by an additional period in which contact sports are
avoided. Early range of motion should be started as soon as pain allows. Com-
plex harness brace devices designed to reduce clavicle fractures (Kenny Howard
type harness) are rarely used in children.
Medial Fractures (Type 3)
Almost all medial clavicle fractures in patients younger than 18 years appear to
be sternoclavicular dislocations but in fact are transphyseal injuries. As noted
earlier the epiphyseal ossification center does not appear until age 18 years and
may fuse as late as age 25 years. If the shaft displaces anteriorly, the chances of
remodeling are excellent, with minimal risk to vital structures. These fractures
are typically treated in a figure-of-8 brace.
If the clavicle displaces posteriorly, the mediastinal structures are at risk (Fig.
6-8). These fractures may be difficult to recognize (the patient may complain of
medial clavicle or sternal pain with difficulty swallowing or breathing). In sus-
pected cases, a CT scan is necessary for diagnosis. If the study shows any im-
pingement or vascular compromise, the fracture should be reduced under gen-
eral anesthesia with a vascular surgeon available.
 Reduction of a posteriorly displaced medial fracture can usually be accom- 81
plished in a closed fashion. A bolster placed between the shoulder blades ele- Treatment
vates the anterior chest. In thin patients, the surgeon can place his/her fingers
behind the clavicle. Upward pressure while the arm is abducted, externally ro-
tated, and extended can relocate the medial clavicle (Fig. 6-9).
If this fails, or the patient is too large for this maneuver, a carefully placed
towel clip can be used to pull the clavicle anteriorly while an assistant applies
lateral traction to the arm (Fig. 6-10). Towel clip application must be judicious
because the subclavian vein lies just below the midshaft of the clavicle. After sta-
ble reduction, the patient is immobilized in a figure-of-8 brace. Open reduction
should be performed if stable reduction cannot be achieved. The physeal frac-
ture can be secured using a strong absorbable suture through the periosteum su-
periorly and/or anteriorly. Postoperative immobilization can be either a figure-
of-8 brace or a shoulder spica.
The patient in Figure 6-10 had swallowing difficulties and his mother noted
a prominent “shoulder blade” 1 month after a motorcycle accident where x-rays
had been read as negative. His primary doctor diagnosed him as having a
winged scapula. We confirmed the diagnosis of medial clavicle fracture with
posterior displacement with a CT scan. The enitre shoulder girdle had rotated
posteriorly causing the appearance of a prominent scapula from the back. The
patient was taken to the operating room for closed reduction; this was not pos-
sible with manual manipulation and a towel clip was required to adequately re-
duce the clavicle. The reduction was unstable and went on to open reduction
and suture fixation.

A B C D

Figure 6-9. A) 14-year-old boy sustained a posteriorly displaced medial clavicle fracture. B) An apical oblique x-ray suggests injury. C) CT
scan confirms posterior displacement (arrow). D) In thin patients, the clavicle can sometimes be reduced using manual manipulation with
traction on the arm. Closed reduction was successful in this patient. He was then placed into a figure-of-8 brace.

R L

A B C

Figure 6-10. A) This 12-year-old boy was referred for a winged scapula 1 month after a motorcycle accident. He also complained of difficulty
swallowing. B) CT scan confirmed a Type 3A clavicle fracture with posterior dislocation. C) He was taken to the OR for closed reduction,
which required a towel clip to pull the clavicle anteriorly.The reduction was unstable and required open reduction and suture stabilization.
82
Clavicle
A
B EXPECTED?
Figure 6-11. A) Some clavicle fractures
create significant deformity and risk the
overlying skin. B) This patient went on to
open reduction and internal fixation to
prevent skin erosion.
Figure 6-12. Lateral clavicle fractures
may lead to a “double clavicle” deformity.
“Nonunion of the clavicle is
supposedly rare in children
but does occur particularly
in muscular, vigorous male
athletes”
Special Fractures
Fractures that compromise the skin, nerves, blood vessels, or mediastinal struc-
tures should be taken to the operating room for closed versus open reduction.
The rare patient with possible subclavian artery injury requires a vascular study
in the preparation for operative intervention. The thick periosteal sleeve makes
suture fixation adequate to control both lateral and medial fractures, especially
in the young child. However, sutures may not be adequate for shaft fractures;
shaft fractures can be fixed with a contoured plate if necessary (Fig. 6-11). Typ-
ically, we use a contourable pelvic reconstruction plate. Smooth pin fixation
should not be used, given the risk for pin migration.
Some centers are now using intramedullary stabilization with elastic nails.
This method of treatment minimizes the unsightly scar that tends to result
from open treatment and is reported to have few major complications. This
method had been used in adults with good results and can be used in a small
percentage of young patients with severely displaced clavicle fractures. Kubiak
and Slongo have reported good results in five pediatric patients treated with in-
tramedullary elastic nails and two treated with external fixation.
PROBLEMS—WHAT CAN BE
In today’s world of competitive sports and manual labor, there is some debate
about the resultant function from clavicle malunions and nonunions. Wilkes
and Hoffer studied clavicle fractures in head-injured children treated with no
immobilization; the conclusion was that excellent results could be obtained
with remodeling of up to 90° of angulation and up to 4 cm of overlap. How-
ever, other studies indicate that greater than 2 cm of overlap predisposes to
nonunion (Wick) and that a “double clavicle” (Fig. 6-12) deformity can de-
velop when nonoperative treatment is selected for more severe distal physeal in-
juries (Ogden).
Malunion/Nonunion of Clavicular Fractures
Nonunion of the clavicle is supposedly rare in children but does occur particu-
larly in muscular, vigorous male athletes. This problem has become widely rec-
ognized in adult clavicular fractures with Hill et al. reporting a fifteen percent
nonunion rate and a 31% “unsatisfactory result” rating in young adult males
with midshaft clavicle fractures. Hill found that in adults, initial shortening of a
clavicle fracture " 20 mm had a highly significant association with nonunion
(p # 0.0001) and the chance of an unsatifactory result. Fifteen percent of the
52 patients in this study with midclavicle fractures had evidence of brachial
plexus irritation, and 28 (54%) had cosmetic complaints. As children age, they
are more likely to have unsatisfactory results from clavicle fractures; therefore
teenagers with displaced fractures must be carefully treated and monitored.
ORIF should be considered with markedly displaced fractures to prevent
nonunion and cosmetic deformities.
Nonunion can lead to continued pain and discomfort with shoulder use. Ul-
trasound has been used to stimulate healing in some cases; the subcutaneous
nature of the clavicle allows easy access for ultrasound or electric stimulation
treatment. If alternative methods fail and the patient continues to have symp-
toms, open reduction should be performed with bone grafting and fixation
with contoured plate (Fig. 6-13).
Nonunion 6 Weeks After Surgery 83
Suggested Readings

At Injury

A B

Figure 6-13. A) 14-year-old boy developed a painful nonunion of his midshaft clavicle fracture.
B) Required open reduction and internal fixation with bone grafting. Six weeks after surgery he
was pain free with full shoulder motion and returned to football 3 months after surgery.
A

Acceptable Results in the High Performance Era 3 Months Later

The cosmetic deformity caused by angulation and callus formation accounts for
the majority of complaints following a clavicle fracture. Armed Forces recruits
with healed clavicle fractures commonly have discomfort when trying to carry a
backpack, which turns the clavicle into a weight-bearing bone. These patients
may require surgical recontouring of the clavicle malunion or osteotomy and
ORIF in severe cases. Acceptable results tend to be determined by the patient
and family. In this era of aggressive athletic performance with thousands of B
teenagers hoping to play college or professional sports that require hyper-
performance of the upper limb (throwing sports), likely better studies will need
to be done to assess what degree of clavicular malunion can lead to long-term
functional compromise in such patients (Fig. 6-14).

SUMMARY
The vast majority of pediatric clavicle fractures can be treated conservatively,
but the surgeon must know how to recognize the few fractures that are life or
limb threatening and require operative intervention.

Suggested Readings Figure 6-14. A) at injury. B) 3 months

Caterini R, Farsetti P, Barletta V. Posttrau-
matic nonunion of the clavicle in a 7-
year-old girl. Arch Orthop Trauma Surg.
1998;117(8):475-6.
Dameron TB. Rockwood CA. Fractures and
dislocations of the shoulder. In Rock-
wood CA, Wilkins KE, King RE. (eds):
Fractures in children. Philadelphia, J.B.
Lippincott, 1984
Eidman DK, Siff SJ, Tullos HS. Acromio-
clavicular lesions in children. Am J Sports
Med. 1981 May-Jun;9(3):150-4.
Goldfarb CA, Bassett GS, Sullivan S, Gor-
don JE. Retrosternal displacement after
physeal fracture of the medial clavicle in
children treatment by open reduction
and internal fixation. J Bone Joint Surg
Br. 2001 Nov;83(8):1168-72.
Hill JM, McGuire MH, Crosby LA. Closed
treatment of displaced middle-third frac-
tures of the clavicle gives poor results.J
Bone Joint Surg Br. 1997 Jul;79(4):537-9.
Kocher MS, Waters PM, Micheli LJ. Upper
extremity injuries in the paediatric athlete.
Sports Med. 2000 Aug;30(2):117-35.
Kubiak R, Slongo T. Operative treatment of
clavicle fractures in children: a review of
21 years. J Pediatr Orthop. 2002 Nov-
Dec;22(6):736-9.
Leighton D, Oudjhane K, Ben Mohammed
H. The sternoclavicular joint in trauma:
retrosternal dislocation versus epiphyseal
fracture. Pediatr Radiol. 1989;20(1-2):
126-7.
Lyons, FA. Migration of pins used in opera-
tions around the shoulder. JBJS 72A:
1262-7
McKee M, Wild L, Schemitz E. Midshaft
malunions of the clavicle. J Bone Joint
Surg (Am). 2003 85A:790-797
Ogden, JA. Distal Clavicular physeal injury.
Clin Orthop 1984; 188:68-73.
Waters PM et al. Short term outcomes after
surgical treatment of traumatic posterior
later. C) Full function. Following a clavicle
fracture patients should be able to return
to full activities and aggressive sports de-
spite apparent deformity.
sternoclavicular fracture-dislocations in
children and adolescents. JPO 23(4):464-
69 2003.
Weinberg B, Seife B, Alonso P. The apical
oblique view of the clavicle: its usefulness
in neonatal and childhood trauma. Skele-
tal Radiol. 991;20(3):201-3.
Wick M, Muller EJ, Kollig E, Muhr G. Mid-
shaft fractures of the clavicle with a short-
ening of more than 2 cm predispose to
nonunion. Arch Orthop Trauma Surg.
2001;121(4):207-11.
Wilkes JA, Hoffer MM. Clavicle fractures in
head-injured children. J Orthop Trauma.
1987;1(1):55-8.
 Shoulder and
7
Humeral Shaft
Maya Pring m Dennis Wenger

• Assessing the Patient 85

• Radiographic Issues 86
• Newborn Fractures 87
• Shoulder Dislocation 87
• Proximal Humerus 88
• Humeral Shaft 92
• Scapula 93

INTRODUCTION
Fractures of the proximal humerus are common during birth and childhood.
“It is difficulties
These fractures have an amazing potential to remodel as they heal; frequently
little intervention is necessary. Of course, as children get older, their remodeling
that show what
potential diminishes and more anatomic reduction is necessary. men are”
Scapula fractures that do not involve the glenoid also heal with little help
from a surgeon; however, the associated injuries must be recognized and treated. —EPICTETUS
ASSESSING THE PATIENT
Localization of a shoulder fracture especially in infants may be difficult. They
may present with what appears to be a brachial plexus palsy because pain will
keep them from moving the arm. You may not be able to determine whether
there is a neurologic deficit until the fracture has healed.
85
86
Shoulder and Humeral Shaft
“Localization of a shoulder
fracture especially in infants
may be difficult. They may
present with what appears to
be a brachial plexus palsy as
pain will keep them from
moving the arm”
Figure 7-1. AP and axillary view of the
proximal humerus. The triangular shape of
the physis makes reading x-rays more diffi-
cult.
Table 7-1 Views to Assess the Child’s Shoulder
AP w/ IR AP w/ ER
Older children are more cooperative with a neurologic exam. The brachial
plexus may be disrupted or stretched by a shoulder injury. The axillary nerve is
easily damaged by fractures or dislocations of the shoulder and can be checked
by testing sensation over the deltoid. Rare cases may also have an arterial injury.
Scapula fractures are typically the result of great violence and associated in-
juries are common. Be sure to look for life-threatening injuries (closed head in-
jury, thoracic trauma, spine fractures, etc.).
Anatomy
The proximal humeral ossification center appears at approximately 6 months of
age. Those for the greater and lesser tuberosity appear around 2 years and 4-5
years, respectively.
The shoulder has a healthy blood supply from the axillary artery and avascu-
lar necrosis (AVN) is rarely a concern.
The shoulder does not have inherent bony stability as the hip does. The
shoulder relies on the capsule and surrounding muscles to maintain its integrity.
It is important to understand the relationship of the bony anatomy to the
brachial plexus.
RADIOGRAPHIC ISSUES
In most emergency departments, an injured shoulder is studied with an AP and
axillary view of the shoulder (Fig. 7-1).
It is difficult to get orthogonal x-rays (two views at right angles) of an injured
shoulder. Often an axillary view is not possible because the child is unable to el-
evate the arm, and moving the arm may further displace the fracture. In such
cases, you should consider a transthoracic lateral or a scapular Y view in addi-
tion to the AP view to properly and safely evaluate shoulder fractures (Table 7-
1). The transthoracic view is difficult to read because the ribs are in the way, but
it gives the best information without moving the extremity.
If the joint is involved, either the glenoid or the humeral epiphysis, a CT
scan will give a clearer picture, allowing you to better evaluate the joint surface.
Ultrasound of the shoulder girdle can help to identify fractures in infants
without the risk of radiation and is a better study if you are concerned about
epiphyseal separation when the head is not yet ossified.
Axillary Transthoracic Scapular-Y
NEWBORN FRACTURES 87
Shoulder Dislocation
Separation of the proximal humeral epiphysis frequently occurs during difficult
deliveries when the shoulder becomes lodged in the pelvic outlet or when the
arm is used to assist in extraction of the infant. The fracture is often difficult to
localize and is frequently confused with a brachial plexus injury until abundant Birth Injury
callus formation is palpable or noted on x-ray. Clinically, the infant may have
an asymmetric Moro reflex as the only sign of injury or may refuse to move the
arm at all. It is often impossible to sort out neurologic injury versus immobility
secondary to the pain of an acute fracture (“pseudoparalysis”).
The vast majority of shoulder girdle fractures sustained during delivery (Fig.
7-2) can be treated by simply pinning the infant's shirt sleeve to the shirt or
using an elastic wrap around the body to immobilize the injured upper extrem-
ity for 2 to 3 weeks. Reduction and/or surgery are virtually never necessary in
this age group. Birth fractures heal extremely quickly with abundant callus for-
mation and remodel leaving little or no residual deformity. Once the fracture
has healed, a better neurologic exam can be completed to evaluate for brachial
plexus injury that may have occurred simultaneously.

SHOULDER DISLOCATION
Traumatic dislocation is typically seen in older adolescents after the epiphyses
have closed (Fig. 7-3). This should be treated as an adult injury with relocation Figure 7-2. Infant humerus fractures are
and immobilization followed by rehabilitation. Anterior dislocations should be often sustained during difficult deliveries.
immobilized in a shoulder immobilizer for 4-6 weeks, whereas posterior dislo- They are easily treated with a few weeks of
immobilization.
cations require a gunslinger splint or spica to maintain the shoulder in external
rotation and abduction. Gunslinger splints are being used more frequently for
anterior dislocations and proximal humerus fractures. The standard shoulder
immobilizer holds the shoulder in internal rotation so the anterior structures
scar down and prevent later external rotation.
Recurrent dislocation has been reported to be as high as 100% following
traumatic dislocation in young patients (Rowe), and many articles report an in-
cidence of 50%-90% regardless of treatment following the first dislocation.
Although many surgical interventions have been described for adults, there
are very few reports of long-term outcomes following surgical intervention in
children and adolescents. Any surgical intervention will require long-term reha-
bilitation with progressive physical therapy starting with gentle pendulum exer-
cises and advancing to active motion and eventually strengthening.
Shoulder dislocations can result in a Hill Sachs lesion, which is an indenta-
tion of the articular surface of the humeral head (Fig. 7-4). They can also result
in a Bankart lesion, which is an avulsion of the anterio-inferior glenoid labrum.
This is the primary lesion in recurrent anterior instability.

Dislocation Normal

Figure 7-4. This is a patient with recur-

Figure 7-3. Traumatic dislocation is typically seen in older adolescents after the epiphyses rent anterior dislocations. Note the ante-
have closed.This should be treated as an adult injury with relocation and immobilization fol- rior subluxation of the humeral head, and
lowed by rehabilitation. the Hill Sachs lesion (arrow).
88
Shoulder and Humeral Shaft
Normal X-ray
Figure 7-5. Tent-shaped physis of proxi-
mal humerus. This pattern often makes
reading of x-rays difficult.
Physeal Stress Injury
Normal
Figure 7-6. Pitchers may pull apart their
proximal humeral physis—on this x-ray,
note the widening of the physis and sclero-
sis signifying chronic stress.The same injury
can also be seen in gymnasts.
“Party trick” dislocation or voluntary dislocation occurs in children with in-
creased joint laxity and typically is not related to an injury. These patients are
treated with strengthening exercises and surgical intervention should be
avoided. Often, these loose-jointed children have difficulty with sports that
stress the shoulder (swimming, throwing—overhead sports).
PROXIMAL HUMERUS
The proximal humerus has a tent-shaped growth plate and very thick posterior
periosteum (Fig. 7-5). The proximal physis contributes 80% of the growth of
the humerus. Force on the shoulder in pediatric patients typically produces a
physeal fracture instead of dislocation as is seen in skeletally mature patients. A
direct blow to the posterior shoulder or a fall on the outstretched hand fre-
quently result in proximal humeral fracture; falls from horses are the most com-
mon mechanism resulting in this type of injury.
Classification
Proximal humerus fractures are broken down into physeal fractures (usually
Salter-Harris I in patients up to age 5 years and Salter-Harris II in older pa-
tients), metaphyseal fractures, and fractures of the greater or lesser tuberosity.
Neer has classified the degree of displacement into four grades:
I. Less than 5 mm displacement
II. One-third displacement
III. Two-thirds displacement
IV. More than two-thirds displacement
About 70% of patients have Grade-I or Grade-II displacement and require
no more than a sling. Several methods of treatment have been advocated for the
more severe grades of displacement.
Chronic proximal humerus separation has been reported in gymnasts, base-
ball pitchers, patients previously treated with radiation, and children with
metabolic abnormalities. Repetitive motion with distractive forces can lead to
physeal stress injuries or separation.
Treatment
Stress injuries to the physis (and the very rare slipped epiphysis) heal with rest
in a sling or shoulder immobilizer for 4 weeks. The most important and most
difficult part of the treatment is to stop the child from continuing the damag-
ing activity (gymnastics or pitching) while the physis heals (Fig. 7-6).
Salter-Harris I fractures can be treated with gentle manipulation with trac-
tion, abduction, and flexion followed by short-term immobilization (3-4
weeks).
Adolescent Salter-Harris II injuries may be difficult to reduce and main-
tain; however, good results are the rule when these fractures are treated con-
servatively. About 70% of patients have mild to moderate displacement
and require no more than a sling. Because 80% of the humeral growth comes
from the proximal physis, this region has a great capacity for remodeling.
The shoulder has a thick muscle cover and malunions tend not to be a cos-
metic problem.
TECHNIQUE TIPS: 89
Immobilization Methods for Humeral Shaft Proximal Humerus

Fractures and Shoulder Injuries

Hanging Arm Cast Shoulder Immobilizer

Most commonly used brace for
shoulder and humerus injuries.

To supply traction to align humeral shaft

fractures.

Sarmiento Brace Gunslinger Brace

Custom brace for stabilization of Keeps the shoulder in external rotation

humeral shaft fractures. to prevent contracture of the anterior
Brace courtesy of Bluebird Orthotics and Pros- capsule.
thetics—San Diego, CA. Photo courtesy of Seattle Systems.

Application of Velpeau Bandage (an inexpensive shoulder immobilizer)

1 2 3

4 5 6
90
Shoulder and Humeral Shaft
At Injury
At Injury
5 Years Later
Figure 7-7. This 6-year-old patient pre-
sented late with this severe Salter-Harris
proximal humeral fracture. Over the next
5 years, the fracture completely remodeled
and she went on to have normal shoulder
function.
At Injury 2 Weeks After Injury
10 Months After Injury 10 Months After Injury—
Malunion and limited motion
10 Months After Injury
Figure 7-8. This teenager with a proximal humerus fracture and apparent mild displace-
ment on x-ray healed with a malunion that slightly decreased her range of motion such that
she was no longer able to play volleyball at a competitive level.
Amazingly, even severely displaced fractures can remodel in young children
(Fig. 7-7).
Risk for Malunion—Need for Reduction
Although young children have excellent remodeling potential, less deformity
can be accepted in a teenager. If the fracture heals with anterior bowing, shoul-
der flexion and abduction will be blocked. With little time remaining for re-
modeling, the patient will be left with a permanent loss of full shoulder motion.
Closed reduction followed by traction or casting with a Statue of Liberty cast
has been described but is mainly of historical interest.
Closed reduction and percutaneous pinning permits the arm to be brought
down to the side while reduction is maintained.
Open reduction is rarely necessary but can be used for fractures that are irre-
ducible into an acceptable position secondary to interposed soft tissue (usually
the biceps tendon) or periosteum. A deltopectoral approach gives adequate ex-
posure for proximal humeral fractures; screw or pin fixation will then maintain
the reduction. Intramedullary rodding can be used with distal insertion (at the
 91
TECHNIQUE TIPS: Proximal Humerus

Closed Reduction and Pinning of Proximal

Humerus Fractures

For significantly displaced proximal humeral fractures in pa-

tients with little remodeling potential (teenagers), closed
reduction and percutaneous pinning is recommended.

A sheet is placed around the body to provide counter trac-

tion. Care must be taken to protect the head and neck.
While maintaining traction, the arm is brought out into ab-
duction and flexion.

Flouroscopy can be used to check AP and axillary views. If

the reduction is unstable, pins can be inserted from the lat-
eral cortex (avoiding the axillary nerve) and into the
humeral head.

We often use K-wires or guide pins for cannulated screws

as the treaded tip prevents early back out of the pins. The
pins are bent and cut outside the skin. To be pulled out in 3
weeks.
92 lateral epicondyle). The 2-mm flexible rods can assist with reduction as well as
Shoulder and Humeral Shaft maintenance of alignment.

Other Fractures of the Proximal Humerus

At Injury
Greenstick fractures are common and can be treated symptomatically. Com-
pletely displaced metaphyseal fractures are more difficult than physeal injuries.
The shaft may penetrate the deltoid to lie subcutaneously. A short incision may
be required to disengage the distal fragment and push it back into place. This is
typically a stable reduction in a sling without internal fixation.
Greater tuberosity fractures are almost never seen in children; on the rare oc-
casion that one is encountered, it can be treated nonoperatively if minimally
displaced. If there is marked displacement, open reduction and internal fixation
6 Months Later should be considered as with adult fractures.
Lesser tuberosity fractures are also rare and can usually be treated sympto-
matically. Athletes that require significant subscapularis strength (competitive
swimmers) may require open reduction and internal fixation to reattach the
subscapularis insertion.
The majority of proximal humerus fractures should be treated non-
operatively because there is an amazing potential for remodeling and excellent
outcome despite significant angulation and displacement (Figs. 7-9, 7-10).
Surgery should not be the first line of treatment but is an option for some se-
vere fractures and special situations as discussed in this chapter.

Figure 7-9. Minimally displaced metaphy-
seal fractures of the proximal humerus can
be treated with a sling or shoulder immo-
bilizer for comfort. They tend to remodel
nicely.
HUMERAL SHAFT
Transverse humeral shaft fractures are the result of a direct blow (Fig. 7-11). Spiral
fractures are produced by a twist; even muscular violence will do this (Fig. 7-12).
Spiral fractures are a common injury in soldiers learning to throw hand grenades.
These fractures are easily treated because they reduce themselves under the influ-
ence of gravity. The only important part of treatment is to maintain good public re-
lations with the family. There are many ways of treating the fracture. A Velpeau
bandage held in place with one roll of plaster or a stockinette Velpeau is simple for
minimally displaced stable fractures. A U-slab provides better fixation. We often use
a hanging arm cast to allow gravity to help reduce the fracture. Sarmiento braces are
an excellent choice for midshaft fractures. We typically splint the patient when the
swelling comes down and then the child is molded for a Sarmiento brace.

1 Year Later
At Injury 6 Months Later

Figure 7-11. Transverse humeral shaft

Figure 7-10. Fractures near the growth physis in a growing child have an amazing potential to fractures are usually the result of a direct
remodel. blow.
 For a week, an attempt should be made to prop the child up at night for 93
sleep. Bayonet apposition is satisfactory because overgrowth of about 1 cm can Scapula
be expected. Varus angulation is common but should be kept at less than 20°.
At the lower end, angular malunion may show and should be corrected; this is
accomplished by manipulating the cast a bit. Immobilization for 3-4 weeks is
sufficient.
Open fractures with bone loss at the lower end may not unite. Grafting and
compression plating may be required and should be carried out before the
elbow becomes stiff.

Pitfalls—Humeral Shaft Fractures

The radial nerve wraps around the humerus and may be injured by the fracture
or the reduction. Radial nerve palsy is particularly likely to occur in fractures at
the junction of the middle and lower thirds of the shaft. The nerve may become
trapped between the fracture fragments. If a nerve palsy is present at presenta-
tion, watchful waiting is usually recommended. Spontaneous recovery can be
expected; look for this first in the brachioradialis. If the fracture remains sepa-
rated by soft tissue interposition, or if a radial nerve palsy follows manipulation,
explore right away; otherwise, save exploration for the child with no signs of re-
covery after 3 months.

Figure 7-12. Spiral humeral fractures are

SCAPULA often sustained after twisting or throwing.

Classification
There are many classification schemes for scapula fractures; however, none are
specific to pediatric patients. The important things to understand and describe
are the location of the fracture within the scapula (body, neck, coracoid,
acromion, or glenoid), associated fractures of the clavicle or AC joint that desta-
bilize the shoulder, and amount of displacement.

Treatment
Fortunately, scapular fractures in children are rare and almost never require spe-
cific treatment. Scapular body fractures tend to heal in adequate alignment re-
gardless of treatment as the muscular envelope maintains the shape of the Figure 7-13. This 16-year-old boy was in
scapula (Fig. 7-13). Isolated body fractures can be treated symptomatically with a motorcross accident and sustained a
a sling or shoulder immobilizer. scapular body fracture. Scapular fractures
Scapular neck fractures in isolation typically do not require anything beyond are typically nondisplaced and heal with lit-
symptomatic treatment; however, if there is an associated clavicle fracture or AC tle intervention, treatment is symptomatic.
dislocation, the shoulder joint becomes destabilized and may require intervention.
In the case of unstable fractures, some recommend open reduction and fixation of
the clavicle to maintain the suspensory function of the scapulo-clavicular complex.
Others recommend ORIF of both the scapular neck and clavicle fracture.
Coracoid fractures with minimal displacement are treated conservatively. “Fortunately scapular
Again, if there is an associated clavicle fracture, some authors recommend
ORIF of at least the clavicle fracture.
fractures in children are rare
Acromial fractures are typically physeal fractures in the pediatric patient and and almost never require
the vast majority can be treated symptomatically with excellent results. Os specific treatment”
acromionale can be a normal finding on x-ray and may be difficult to distin-
guish from a fracture. X-rays of the contralateral shoulder will help to differen-
tiate fracture from a normal anatomic variant.
94 Glenoid fractures are the scapular fractures most likely to lead to arthritis
Shoulder and Humeral Shaft and disability later in life. As with most joints, a step-off greater than 2 mm is
not well tolerated and every effort should be made to obtain anatomic align-
ment. The glenoid is very difficult to approach through an open incision and
internal fixation is difficult given the anatomy of the scapula with its paper thin
body; so many surgeons prefer nonoperative methods when possible. Skeletal
traction can be used or early range of motion to attempt to recontour the gle-
noid during the early healing process. If the equipment and expertise are avail-
able, glenoid fractures can be reduced and fixed arthroscopically.

Suggested Readings
Beringer DC, Weiner DS, Noble JS, Bell RH.
Severely displaced proximal humeral epi-
physeal fractures: a follow-up study. J
Pediatr Orthop. 1998 Jan-Feb;18(1):31-7.
Dameron TB, Reibel DB: Fractures involv-
ing the proximal humeral epiphyseal
plate. J Bone Joint Surg 51A:289, 1969.
Deitch J, Mehlman CT, Foad SL, Obbehat
A, Mallory M. Traumatic anterior shoul-
der dislocation in adolescents. Am J
Sports Med. 2003 Sep-Oct;31(5):758-63.
Dobbs MB, Luhmann SL, Gordon JE,
Strecker WB, Schoenecker PL. Severely
displaced proximal humeral epiphyseal
fractures. J Pediatr Orthop. 2003 Mar-
Apr;23(2):208-15.
Goldberg BJ, Nirschl RP, McConnell JP,
Petttrone FA. Arthroscopic transglenoid
suture capsulolabral repairs: preliminary
results. Am J Sports Med. 1993 Sep-
Oct;21(5):656-64; discussion 664-5.
Lawton RL, Choudhury S, Mansat P,
Cofield RH, Stans AA. Pediatric shoulder
instability: presentation, findings, treat-
ment, and outcomes. J Pediatr Orthop.
2002 Jan-Feb;22(1):52-61.
Moore EM: Epiphyseal fractures of the supe-
rior extremity of the humerus. Trans Am
Med Assoc 25:296,1974.
Neer CS, Horwitz BS: Fractures of the proxi-
mal epiphyseal plate. Clin Orthop 41:24,
1965.
Rowe CR, Pierce DS, Clark JG: Voluntary
dislocation of the shoulder. J Bone Joint
Surg 55A:445, 1973.
Smith FM: Fracture - separation of the prox-
imal humeral epiphysis. Am J Surg
91:627, 1956.
Visser CP, Coene LN, Brand R, Tavy DL.
Nerve lesions in proximal humeral frac-
tures. J Shoulder Elbow Surg. 2001 Sep-
Oct;10(5):421-7.
Williams DJ: The mechanisms producing
fracture—separation of the proximal
humeral epiphysis. J Bone Joint Surg
63B:102, 1981.
 Elbow—Distal Humerus
8
Maya Pring m Mercer Rang m Dennis Wenger

• Assessing the Patient 96

• Radiographic Issues 98
• Transphyseal Distal Humerus
Fractures 100
• Supracondylar Fractures 102
• Lateral Condyle Fractures 112
• Medial Condyle Fractures 115
• Medial Epicondyle Fractures 116
• Lateral Epicondyle Fractures 118

INTRODUCTION
The last edition of this book started the elbow chapter with “Pity the young
“We retain from
surgeon whose first case is a fracture around the elbow…at every stage these
fractures present difficulties: difficulties of diagnosis and reduction, vascular
our studies only
and neurologic problems, slippage in the cast, malunion, and stiffness.” that which we
However, in 1995, Rang and Gillingham revised the statement to “it is no
longer necessary to pity the young surgeon whose first case is a child’s elbow practically apply”
fracture. Current education will have prepared him or her for it. Save pity for
the old surgeon unacquainted with the advances that have taken place in the di- —GOETHE
agnosis and treatment of elbow fractures. Modern methods have improved out-
come but are more technical. Technical skills, once mastered, are inclined to
rust without use. The gap between those who can pin an elbow and those who
cannot continues to widen.”
95
96
Elbow—Distal Humerus
“It is no longer necessary to
pity the young surgeon whose
first case is a child’s elbow
fracture”
“The elbow, more than most
other joints, can readily
become stiff following injury
or surgery”
Although they are not simple fractures, the goal of this chapter is to help you
recognize and treat pediatric elbow fractures while avoiding the complications
that are abundant in the older literature.
Anatomy
The elbow is a sophisticated joint composed of three separate articulations: ra-
diocapitelar, proximal radioulnar, and ulnohumeral. The spiral orientation of
the trochlea allows flexion and extension about an oblique axis; this brings the
forearm from a position parallel to the humerus in full flexion to a valgus carry-
ing angle of 15° in extension (Fig 8-1).
The carrying angle has evolutionary significance, allowing the upper extrem-
ity to carry an item with clearance of the pelvis as the arm swings. Females have
a slightly greater carrying angle because the pelvis is wider.
The elbow also allows pronation and supination about the long axis of the
forearm (Fig. 8-2). These complex motions require maintenance of an anatomic
relationship between all three articulations. Fracture management requires an
understanding as to what degree of angle change or displacement requires surgi-
cal intervention. Unfortunately, anatomic reduction and union do not guaran-
tee good postinjury motion.
The elbow, more than most other joints, can readily become stiff following
injury or surgery. Often, the surgeon must make the difficult decision of early
motion (and risk for non-union) versus cast immobilization (and possible stiff-
ness). In addition to complex design issues, there are multiple growth plates
near the elbow that fractures often traverse. If not properly treated, this can lead
to nonunion or growth arrest.
ASSESSING THE PATIENT
In the busy season, we may see 50 injured and/or swollen elbows each week. As a
note of precaution, on initial exam, it may be very difficult to distinguish between
an injured and an infected elbow in a young child. At least twice a year, we see a
child with a history of trauma and a swollen elbow who turns out to have a septic
Figure 8-1. The trochlea has a spiral orientation
that brings the forearm from in-line with the Figure 8-2. In addition to flexion and
humerus in flexion to a carrying angle of 15°‚ val- extension, the elbow allows ~90° of
gus in extension. supination. and pronation.
joint. Never let the history of trauma lead you away from suspecting infection, es- 97
pecially in a young child with a “soft” history (a soft history often consists of “she Assessing the Patient
has a sore elbow since yesterday. Her six-year-old sister says she “fell down”). The
questions regarding who observed the injury must be precise. Did the child
scream with pain immediately? Who observed this? If the picture is not clear,
order a complete blood count (CBC), sedimentation rate, and C-reactive protein “The questions regarding
to rule out infection. who observed the injury
Once the area of concern is identified, gentle palpation may help with frac-
ture localization, but this is often difficult in an uncomfortable young child
must be precise. Did the
with a painful elbow. Carefully examine the skin to rule out an open fracture. child scream with pain
Check areas where the skin is tented or at-risk; the sharp bone ends of a dis- immediately? Who observed
placed supracondylar fracture can easily penetrate the skin; a closed fracture
may be only a cell layer or two from an open fracture. this? If the picture is not
The contralateral elbow should be examined to determine the normal carry- clear order a CBC, sed rate,
ing angle and the child’s natural ligamentous laxity or ability to hyperextend. and CRP to rule out
Next, the examiner proceeds with vascular assessment; radial pulses should
be symmetric and capillary refill less than 2 seconds. If pulses are not palpable, a infection”
Doppler can be used to check for blood flow to the hand. A dysvascular hand is
an emergency and should be taken to the operating room (OR) for immediate
reduction. A compartment syndrome can also impede blood flow and must be
addressed immediately (see Chapter 19).
Older children can comply with your neurologic exam: test the radial nerve
by asking the child to extend the thumb (Table 8-1). Anterior interosseous
nerve testing includes flexion of the distal interphalangeal joint of the index fin-
ger and the interphalangeal joint of the thumb. The ability to grasp indicates
median nerve function, and finger spread and ability to cross the fingers indi-
cates that the ulnar nerve is functioning. Test sensation to light touch and/or 2-
point discrimination on the radial and ulnar sides of each digit and over the
dorsum of the thenar web.
Unfortunately, young injured children are not capable of complying with
this neurologic exam; avoid documenting that the patient is “neurovascularly
intact” (NVI) unless each test has been successfully performed. Document only
what you can effectively test; if the patient has a nerve palsy postoperatively and
you have written NVI on the initial exam sheet, it may be difficult to prove that
the nerve injury was not caused by the reduction (or surgery).
The neurovascular status of the upper extremity must be monitored carefully
until definitive treatment is completed and for at least 24 hours following treat-

Table 8-1 Quick Motor Nerve Testing for the Upper Extremity

“Thumbs up” “OK”

Note EPL
function

Radial nerve—Extension of wrist and thumb Unlar nerve—Abduction of digits 3-5

Median nerve—Flexion of digits 2-3 Anterior interosseous nerve—Flexion of index and thumb DIP
98
Elbow—Distal Humerus
AP
Figure 8-5. Lateral condyle fractures may be difficult to see on AP and lateral x-rays—oblique x-rays show the true
displacement of the fracture (arrow).
A B
Figure 8-6. A) The occult fracture B) was
better understood once callus formed
after 3 weeks of casting.
Figure 8-7. Age at ossification of the dis-
tal humerus growth centers for males and
females. (Adapted from Haraldsson.)
Figure 8-3. Volkmann’s ischmic contrac-
Figure 8-4. “Loser’s view”—with the elbow
ture, a dreaded complication of a supra-
flexed. It may be difficult to get a true AP of
condylar fracture, is much less common in
the distal humerus or proximal forearm.
the era of percutaneous pinning.
Lateral Oblique
ment. The risk of compartment syndrome and Volkmann’s contracture (Fig. 8-3)
is increased by casting and by elbow flexion of more than 90°. For arms that are
at risk of developing compartment syndrome following difficult reductions, it is
better to use a posterior splint with the elbow in less than 80° of flexion until
the swelling has resolved.
RADIOGRAPHIC ISSUES
Obtaining true AP and lateral x-rays in the injured child can test even the best
radiology technician. Some radiology departments deliver a “loser’s” view (Fig.
8-4)—an AP view of an elbow flexed about 90°, which makes diagnosis more
difficult. Don’t be bashful about insisting on a true AP of the distal humerus
and of the proximal forearm, even if two or more views must be taken. Correct
diagnosis is everything. Sometimes only the conviction that there must be a
fracture will drive the clinician to obtain oblique films of the joint, radiographs
of the normal elbow, or even stress films.
Although many fractures are obvious on the AP and lateral x-ray, some are
not. Occult fractures may be detected only by clinical suspicion and a careful
study of the soft tissue on x-ray. The displacement of lateral condyle fractures
may only be visible on oblique x-rays (Fig. 8-5); if there is any question about
the direction or amount of displacement, four views (AP, lateral, and two
oblique views) will help. The fracture is sometimes only visualized when callus
begins to form after 3 weeks of immobilization (Fig. 8-6).
Growth plates cause much confusion for those who do not regularly treat
children’s fractures. Fortunately, the opposite elbow can be radiographed as a
control, which is extremely useful in determining the normal anatomy for a 99
particular child. Understanding the timing of growth center ossification and fu- Radiographic Issues
sion helps the orthopedic surgeon in evaluating an elbow injury, but it is gener-
ally not part of a primary doctor’s training (Fig. 8-7).
Even for the experienced pediatric orthopedist, there are times when the
exact diagnosis remains elusive. Some cases may require an arthrogram, CT, or
MRI to further clarify the fracture. This is most likely in young children in
whom much of the elbow remains as radiolucent cartilage.

X-ray Landmarks
Several x-ray landmarks help in evaluating an injured elbow:
Baumann’s angle on the standard AP x-ray assesses the angulation of the
physeal line (of the lateral condyle) in relation to the long axis of the humeral
shaft (Fig. 8-8). A normal Baumann’s angle is approximately 20°. A decrease in
Baumann’s angle (0° for example) suggests cubitus varus.
The anterior humeral line on the lateral view should pass through the middle
third of the ossification center of the capitellum. The anterior humeral line of
an extension type supracondylar fracture will intersect the capitellum more an-
teriorly or may not intersect it at all (Fig. 8-9).
On the lateral x-ray, the shaft-condylar angle should be about 40°. A decrease
in this angle suggests hyperextension through the fracture site (Fig. 8-10).
Fat pad sign (often referred to as a sail sign) is a small amount of fat that over-
lies the elbow joint both anteriorly and posteriorly. With injury (or sepsis) and
elbow swelling, the fat is pushed away from the bone and may be visible on a
high-quality lateral x-ray. An anterior fat pad is a normal finding on many pedi-

B
B C
A
Figure 8-8. A) Baumann’s angle. B) Normal elbow—BA is 20°. C) Cubitus varus—BA is 5°. A

Anterior
Humeral
Line
-20˚

C D
A B C D
Figure 8-10. A-B) A normal shaft-
Figure 8-9. A-B) The anterior humeral line should intersect the middle third of the capitel- condylar angle is ~ 40°. C-D) This angle
lum. C-D) If the anterior humeral line is anterior to the capitellum, the extension supra- decreases with extension of a supra-
condylar fracture needs to be reduced. condylar fracture.
100
Elbow—Distal Humerus
Figure 8-11. Transphyseal fractures may
be confused with an elbow dislocation on
x-ray. Remember that elbow dislocations in
children are rare without an associated
fracture.
Table 8-2 Distal Humerus Fat Pad Sign (Sail Sign)
A posterior fat pad or so-called sail sign strongly suggests an occult elbow
fracture.You may not know what type of fracture for 10–14 days when cal-
lus appears.
Normal
(Note—a small anterior
fat pad sign is often normal)
Anterior Fat Pad
(Large anterior fat pad;
Dx—supracondylar fracture)
Anterior and Posterior Fat Pad
(Dx—supracondylar fracture)
atric elbow x-rays; a posterior fat pad on x-ray often indicates an occult fracture
about the elbow (Table 8-2).
With a posterior fat pad sign and no obvious fracture, oblique x-rays should be
obtained to help rule out medial or lateral condyle fractures. Skaggs and Mirza-
yan prospectively examined a group of children with acute elbow trauma and a
posterior fat pad sign without a visible fracture on AP and lateral x-rays. At 3
weeks, new radiographs were taken and were evaluated for signs of fracture
healing; they found that 34 out of 45 patients (76%) had evidence of an elbow
fracture. These included:
! Supracondylar fractures—53%
! Proximal ulna fractures—26%
! Lateral condyle fractures—12%
! Radial neck fractures—9%
FRACTURE TYPES:
TRANSPHYSEAL DISTAL HUMERUS
FRACTURES
Separation of the distal humeral epiphysis in an infant with an unossified epi-
physis looks like a dislocation (Fig. 8-11). Remember that dislocation of the
elbow without an associated fracture is very rare in children. Transphyseal distal
humerus fractures are frequently associated with child abuse and warrant fur-
ther investigation. They occur only in young children.
 Typically the distal fragment is displaced posteriorly and medially, so the 101
alignment of the proximal radius and ulna are no longer in line with the distal Transphyseal Distal Humerus Fractures
humerus. In comparison (although extremely rare in young children), elbow
dislocations usually have posterolateral displacement of the proximal radius and
ulna. If there is inadequate ossification to evaluate the fracture on plain films, “Transphyseal distal
an ultrasound study or arthrogram can help to classify the diagnosis.
Many of these injuries have a small piece of the distal metaphyseal bone at- humerus fractures are
tached to the physis and are thus technically a Salter-Harris II fracture pattern. frequently associated with
Radiographic evidence of this small Thurston-Holland triangular fragment plus
posteromedial displacement of the proximal radius and ulna helps to confirm
child abuse and warrant
the diagnosis. further investigation”

Classification—Transphyseal Fractures
Delee classified transphyseal fractures into three groups (Table 8-3) based on
the degree of ossification of the lateral condylar epiphysis (lateral condyle begins At Injury 3 Weeks
to ossify around 1 year of age). Group A fractures are Salter-Harris type I.
Group B fractures can be Salter-Harris I or II. Group C fractures are classified
as Salter-Harris II and are identified by the metaphyseal fragment (also know as
a Thurston-Holland fragment) that remains with the epiphysis (see Chapter 14
for further description of the Thurston-Holland fragment).

Treatment—Transphyseal Fractures
If the fracture is diagnosed early (less than 5 days), closed reduction plus cast
immobilization is recommended for transphyseal fractures (Fig. 8-12). Keeping 6 Weeks
the arm flexed and pronated assists with maintaining the reduction, allowing
casting in this position as treatment for infants.
Older children have a greater risk for cubitus varus and usually require per-
cutaneous pinning following closed reduction; two lateral pins are adequate
with the pins left in place to maintain alignment for 3 weeks until healing is
complete. An arthrogram can be used to confirm the reduction if there is insuf-
ficient ossified bone to confirm fragment position.
Frequently, children are brought in late with transphyseal fractures (particu-
Figure 8-12. Transphyseal fracture sus-
larly if they are secondary to child abuse); if the fracture is more than 5 days tained during delivery healed with signifi-
old, or there is periosteal new bone noted on x-ray, the fracture should probably cant callus at 3 weeks.At follow-up the pa-
not be reduced because the reduction maneuver may cause further damage to tient had full range of motion at the elbow.

Table 8-3 Delee Classification of Transphyseal Fractures

Group A—0–12 months Group B—1–3 years Group C—3–7 years

No ossification of lateral Ossification of lateral condyle, Ossification of lateral condyle,

condyle, usually SH I can be SH I or SH II with small usually SH II with large
metaphyseal fragment metaphyseal fragment
102
Elbow—Distal Humerus
At Injury
After Treatment
Figure 8-13. Transphyseal fracture of dis-
tal humerus in a child. One must think of
child abuse in such a case. A) At injury. B)
After reduction plus K-wire fixation.
Figure 8-14. Cubitus varus is the most
common late deformity following an undiag-
nosed and untreated transphyseal fracture.
the physis. Such fractures should be splinted or casted for comfort and often ad-
equate remodeling occurs in infants. If there is not sufficient remodeling, an os-
teotomy can be done to correct alignment when the patient is older.
Pitfalls—Transphyseal Fractures
Recognizing the injury as a “classic sign” of child abuse and completing a social
workup prior to discharge may be may be the most important issue for future
safety of the child. Failure to identify transphyseal fractures is a common pitfall
(Fig. 8-13), with cubitus varus the most common deformity following under-
treated transphyseal fractures (Fig. 8-14).
The vascular supply to the medial crista of the trochlea travels through the
physis and injury to this blood supply can cause avascular necrosis (AVN) of the
trochlea. Yoo reported 8 patients who developed AVN of the trochlea following
transphyseal distal humerus fractures. This appears as a “fishtail” defect on
x-rays (Fig. 8-15).
SUPRACONDYLAR FRACTURES
Supracondylar fractures are produced by forcibly hyperextending the elbow.
The level of the fracture is determined by the olecranon forming a fulcrum in
the supracondylar region (Fig. 8-16); the collateral ligaments of the elbow at-
tached to the metaphysis usually prevent dislocation.
These fractures are more common in children with naturally hyperextendible
joints, likely because a 10°-20° normal hyperextension makes the lever arm
more efficient. Traditionally, boys were reported to be at higher risk of sustain-
ing supracondylar fractures, but our series showed a slight preponderance for
girls to sustain this injury. Females more commonly have natural joint hyper-
extensibility as compared to their male counterparts, which may increase their
risk. Also in our area, females lead a very rigorous sporting life, earning the
honor of a supracondylar fracture incidence equal to or greater then their male
counter parts.
In experiments, the periosteum remains intact so long as the force is pure hy-
perextension. When the fracture is forcibly rotated, the sharp corner of the
proximal fragment tears the periosteum, permitting gross displacement (Fig. 8-
17). With progressively more force, the sharp edge will first tear the brachialis
and then the skin. It also puts the neurovascular structures at risk.
Figure 8-16. The olecranon forms a fulcrum in
Figure 8-15. AVN of the trochlea causes the supracondylar region, which causes a frac-
a fish-tail deformity of the distal humerus. ture when the elbow is forcibly hyperextended.
 Nerve injuries are usually transient stretch injuries and are relatively com- 103
mon in displaced supracondylar fractures, Campbell reported a 49% incidence Type I Supracondylar Fractures
of neurovascular compromise in patients evaluated for type III supracondylar
fractures. Fifty-two percent of the injuries were to the median nerve (usually
with posterolateral displacement) and 28% to the radial nerve (all from pos-
teromedial displacement). “Traditionally, boys were
reported to be at higher risk
Classification—Supracondylar Fractures of sustaining supracondylar
The standard classification of supracondylar humerus fractures includes exten- fractures, but our series
sion and flexion types; flexion type fractures are much less common with the showed a slight
distal fragment anterior to the shaft on the lateral x-ray. The more common ex-
tension fractures are classified as types I through III. Type I are minimally dis- preponderance for girls to
placed, type II are extended but have a posterior hinge, and type III are com- sustain this injury.”
pletely displaced. Extension fractures can be further subdivided as described in
Table 8-4.

Treatment—Supracondylar Fractures
Prior to definitive management, the elbow should be splinted in about 30° of
flexion. Flexing a displaced supracondylar fracture in a splint tends to compress
the neurovascular structures. Also, splinting in full extension may increase pres-
sure in the neurovascular structures (by spicules of the fractured distal
humerus). It is foolish to have a child waiting for radiographs with an ischemic
limb. Put the splint on before the radiographs are taken to keep the technician
from twisting the arm through the fracture.
Specific treatment of this injury has two goals:
1. Avoiding neurologic and vascular problems
2. Preventing long-term angular (usually cubitus varus) and extension deformity
Cubitus varus used to be thought of as a “cosmetic deformity” but is now
recognized as a condition that places the child at risk for later fractures, specifi- Figure 8-17. Rotation through the frac-
cally lateral condyle fractures (Davids et al.). ture may cause the sharp anterior spike to
tear through the brachialis and skin.

TYPE I SUPRACONDYLAR FRACTURES

Most type I supracondylar fractures can be treated with cast immobilization “Cubitus varus used to be
(for about 3 weeks). Prior to deciding on conservative management, the con-
tralateral elbow should be checked for hyperextension. If the patient naturally
thought of as a ‘cosmetic
has significant laxity and hyperextension (as determined by examining the nor- deformity’ but is now
mal elbow), even a mild increase in this extension due to a slightly extended recognized as a condition
supracondylar fracture can lead to significant deformity (Fig. 8-18). Thus the
that places the child at risk
for later fractures
(specifically lateral condyle
fractures)”

Figure 8-18. Patients with natural hy-

perextension may be at increased risk of
supracondylar fractures. Allowing a
supracondylar fracture to heal slightly
extended may cause gross deformity in a
hyperlax child (and put them at risk for
re-fracture).
104 more naturally lax the child, the greater the indication for reduction. During
Elbow—Distal Humerus the period of cast immobilization, it is important to monitor with radiographs
to ensure that the fracture does not displace into further extension or varus.
Type IA are typically very stable fractures, but type IB may slowly collapse into
varus because of the medial cortical buckle. Failure to recognize a IB fracture may

Table 8-4 Classification of Supracondylar Fractures

Extension Fractures Displacement

TYPE IA Nondisplaced, no varus or valgus,

capitellum, anterior humeral
line on lateral x-ray

TYPE IB Minimally displaced with medial

cortex buckle, capitellum intersected
by anterior humeral line

TYPE IIA Extended, posterior cortex intact,

capitellum posterior to anterior
humeral line—no rotation

TYPE IIB Straight or rotatory displacement,

still some fracture contact

TYPE IIIA Completely displaced posteriorly,

no cortical contact. Most common
posteromedial displacement

TYPE IIIB Wide displacement with soft tissue gap

between bone ends, and significant
overlap and/or rotatory displacement
with no fracture contact

FLEXION-TYPE FRACTURES Displaced anteriorly (rare)

lead to a poor result and cubitus varus if conservative management is chosen and 105
the patient is not followed closely. The cast should be appropriately molded to try Type II Supracondylar Fractures
to counteract the varus collapse, and a gentle thumb-print in the olecranon fossa
can help to prevent further extension of a supracondylar fracture (Fig. 8-19).

TYPE II SUPRACONDYLAR FRACTURES

Type II fractures need to be reduced to prevent hyperextension and angular de-
formity of the elbow. These injuries often appear to be in a single plane; how-
ever, it is also important to evaluate and correct any varus angulation or rota-
tion. Although closed reduction can be maintained with casting or splinting in
hyperflexion, this significantly increases the risk of neurovascular compromise
to the extremity and is no longer recommended in centers where the skills and
equipment are available for percutaneous pinning.
Type IIA fractures are in only one plane and some advocate treating them in
a cast; we prefer to reduce and pin all type II fractures. Type IIB fractures have a
rotational component that make reduction and maintenance of reduction more
difficult; no one argues that these fractures require pinning.
Percutaneous pinning maintains the fracture reduction while allowing a safe
casting position (flexion of !90°). The majority of supracondylar fractures have
a posteromedial hinge of the periosteum that aids in the reduction process (Fig.
8-20).

Figure 8-19. For type I supracondylar

fractures the cast can be molded gently
with your thumb to prevent extension of
the fragment. Be careful not to overmold
and create skin necrosis. (Method of Klaus
Parsch—Stuttgart, Germany.)

Figure 8-20. The periosteum usually remains intact on one side of the fracture allowing it to
act as a hinge for reduction. In most supracondylar fractures, the distal fragment displaces medi-
ally and the medial hinge is intact. This allows a repeatable sequence for reduction with the
elbow extended and supinated, then gentle flexion and pronation typically reduces the fracture.

Table 8-5 Acceptable Configuration of K-wires for Supracondylar Fractures

Divergent—2 pins 3 pins Crossed Crossed and Divergent

Two lateral pins adequate for Three lateral pins for very Traditional fixation puts A third pin can be added for
most fractures unstable fractures ulnar nerve at risk unstable fractures. If necessary,
the medial pin can be removed
once the cast is on.
106
Elbow—Distal Humerus TECHNIQUE TIPS:
Reducing Supracondylar Fractures

The majority of supracondylar fractures displace in a

postero-medial direction and can be reduced in a repro-
ducible fashion.

Position patient supine with armboard.

Fluoro (from head of bed and paralled to bed).
Monitor (easy for surgeon to see without turning head).

Milk soft tissue out of fracture.

Initially, keep the elbow extended and supinated.
Under image control, align the fracture on AP with trac-
tion and varus or valgus pressure.

Only after the AP view is aligned should flexion be

attempted.
Maintain traction (anesthesia can help with a sheet
around the chest for counter traction).
Flex elbow up with thumb gently behind olecranon. (Do
not over-reduce and convert to flexion-type fracture!)
Gradually pronate the arm as you flex it.

The elbow is flexed to ~130˚ with full forearm prona-

tion.
If fracture is unstable the fluoro should be rotated while
maintaining elbow position to avoid loss of reduction to
obtain the lateral x-ray.
 107
TECHNIQUE TIPS: Type II Supracondylar Fractures
Pinning Supracondylar Fractures

Following reduction, hold the humerus parallel to the

floor with the elbow flexed to 130˚.
Start the first pin just lateral to the olecranon through
the capitellum.
Aim at ~ 45˚ toward the medial metaphyseal cortex.

Start the second pin more proximally and diverge from

the first.
Aim toward the medial diaphyseal cortex.
Make sure all pins penetrate the medial cortex.

If reduction is not stable, consider a third lateral or me-

dial pin.

For medial pin, palpate the ulnar nerve with thumb and
push nerve posteriorly.
Extend the elbow and insert pin anterior to thumb.

Bend the pins to a 90˚ angle as close to skin as possible.

Cut the pins ~ 2 cm distal to bend.
Place felt over the pins to protect the skin.
Cast the elbow with < 80˚ of flexion and split the cast to
allow for swelling.
108
Elbow—Distal Humerus
Figure 8-21. Fractures that exit very dis-
tally on the lateral side are difficult to sta-
bilize with only lateral pins. A medial pin is
frequently necessary.
Error—Not Stable
Figure 8-22. Pins that cross at the frac-
ture line are rotationally unstable and
should be avoided.
Pinning Patterns
There is debate as to the optimal number and configuration of K-wires; two or
three pins can be used to stabilize most supracondylar fractures. Traditionally, cross
pinning (one pin from medial and one from lateral) was performed. Currently, for
typical supracondylar fractures, most centers use two or three pins from the lateral
side to avoid ulnar nerve injury. Typically, two pins are adequate for type II frac-
tures and three pins are frequently used to stabilize type III fractures.
Pins should diverge to create maximum space between them at the fracture
site; they should not cross at the fracture site because this creates a rotationally
unstable configuration (Table 8-5). When using a medial pin, one must avoid
the ulnar nerve. This pin should not be placed with the elbow flexed, because
flexion moves the ulnar nerve anteriorly putting it closer to the entry site of the
K-wire.
For a typical fracture, two lateral divergent pins are adequate fixation. We rec-
ommend placing two lateral pins, and, if the reduction is felt to be unstable, a
third lateral or medial pin can be added. If the fracture line exits far distally on
the lateral side, a medial pin may be necessary for stabilization (Figs. 8-21, 8-22).
For medial pin placement, extend the elbow to allow the nerve to fall poste-
riorly. The ulnar nerve can be palpated and pushed more posteriorly with your
thumb allowing safe medial pin entry. With a three-pin technique, if two lateral
pins are in place and the patient wakes up with an ulnar nerve palsy, the medial
pin can be removed through a window in the cast and the fracture will likely re-
main stable. If there is only a single lateral pin, this is not usually enough to
maintain the reduction if the medial pin has to be removed.
TYPE III SUPRACONDYLAR FRACTURES
All type III fractures require reduction and internal fixation (there is often a ro-
tational component that when added to the complete displacement can make
reduction very difficult). In parts of the world where technology for safe percu-
taneus pinning is not available, traction methods (Fig. 8-23, Fig. 8-24) can be

Figure 8-23. Bed traction can be used to align a

supracondylar fracture but is not commonly used if
equipment and skills for pinning are available. Accu-
rate reduction is less likely; however, this simple
method may be the only choice in certain parts of
the world.
(Adapted from Blount. Fractures in children.)
Figure 8-24. Overhead skeletal trac-
tion can be used to align a severe
supracondylar fracture, again, results
are inferior to closed reduction and
percutaneus pinning.
Figure 8-25. The humerus at the level of
a supracondylar fracture is shaped like a
fish tail: its narrowness can turn a stable re-
duction into a balancing act.
used but are not as effective, with residual cubitus varus common. At the level 109
of a supracondylar fracture, the bone is extremely narrow and shaped like a fish Type III Supracondylar Fractures
tail—turning a stable reduction into a balancing act (Fig 8-25).
Frequently reduction can be done in a closed fashion with associated percu-
taneous pinning, but the fracture on occasion needs to be opened if soft tissue
interposition prevents anatomic reduction or if there has been injury to the
brachial artery. An ischemic hand is a surgical emergency, which will be ad-
dressed later in this section. The absence of a radial pulse is not an indication
for exploration if the fingers are pink and can be painlessly extended; the
brachial artery is likely in spasm and circulation can be monitored following re-
duction if the extremity is still adequately perfused.
Prior to attempting reduction of a type III fracture, one can “milk” the soft
tissues down the arm; this may pop the interposed tissue out of the fracture site.
Puckered skin on the anterior aspect of the elbow indicates soft tissue and on
occasion brachial artery entrapment (Fig. 8-26).
We have had several cases where the ulnar nerve was entrapped in the fracture
site and prevented anatomic reduction (Fig. 8-27). If persistent medial fracture
gap remains, the surgeon should consider making an incision rather than repeat-
edly grinding the bone ends against a nerve, vessel, or other interposed soft tissue.
The incision for opening supracondylar fractures depends on the fracture; the
most direct approach is usually directly over the prominent bony fragment
whether it is anterior, medial, or lateral. Care needs to be taken to protect the
brachial artery and median and radial nerves during the exposure and reduction.

Postoperative Care
Following closed reduction and percutaneous pinning of a supracondylar fracture, Figure 8-26. “Puckered” skin on the an-
the type of immobilization will depend on the amount of soft tissue injury and terior aspect of the elbow indicates soft
risk of swelling. Type 2 fractures with moderate swelling and a single reduction tissue entrapment.
maneuver can be placed in a cast flexed to about 80° at the elbow, as long as the
cast is split (univalved). The cast can be tightened and overwrapped in 1 week.
Type III fractures should generally not be immediately casted unless the cast
is bivalved and the web-roll split to allow for swelling. A better choice is a long
posterior splint for the first week, which can then be converted to an above After Closed
elbow cast. We recommend monitoring patients in the hospital overnight fol- Reduction After Open
lowing percutaneous pinning of a supracondylar fractures to ensure that any Attempt Reduction
neurovascular compromise is recognized and treated early.
Three weeks following surgery, the cast can be removed and the percuta-
neous pins can be removed in the clinic—sedation is almost never used. Pins
should not be left in longer than 3 weeks given the risk of infection and the ten-
dency for supracondylar fractures to heal quickly. In the majority of cases, there
is adequate healing to begin motion at this time. A few fractures will remain
clearly visible with little callus and require a second cast or splint for 2-3 weeks.
However, it should be noted that supracondylar fractures rarely displace after 3
weeks, and the risk for stiffness increases if the elbow is immobilized in flexion
longer than 3 weeks. This is in contrast to lateral condyle fractures that need the
A B
pins maintained for 4 weeks and occasionally longer to avoid nonunion. Physi-
cal therapy is rearely needed to regain elbow motion (Fig. 8-28). Figure 8-27. A) This was the best reduc-
tion that could be obtained closed; there
was concern about the medial fracture gap.
The Pulseless Arm B) The fracture was opened and the ulnar
nerve was found in the fracture, blocking
Few cases raise the new-to-practice orthopedists stress titer more than a severe reduction. Once the nerve was removed
supracondylar fracture with vascular compromise. Concerns remain, although from the fracture, anatomic reduction could
the incidence of vascular complications has decreased with early recognition, ad- be obtained.
110
Elbow—Distal Humerus
“Few cases raise the new-to-
practice orthopaedists stress
titer more than a severe
supracondylar fracture with
vascular compromise”
Figure 8-28. Physical therapy may be
painful and is unlikely to improve motion fol-
lowing malunion of a supracondylar fracture.
(Adapted from Blount. Fractures in children.)
Figure 8-29. Gunstock deformity: This boy has residual varus and extension of the right elbow following nonoperative treatment of a
supracondylar fracture.
vanced techniques for closed reduction and percutaneous pinning, and avoid-
ance of hyperflexion. Over the last 10 years, a gradual consensus has evolved that
allows effective treatment of the pulseless arm (see Technique Tips).
Historically, the “5 Ps” (pain, pallor, paresthesias, paralysis, pulselessness) were
considered the most important signs of ischemia; however, these are late signs
and a surgeon should never wait to treat a compromised arm if these symptoms
are not present. Copley et al. reviewed a large series of patients with type III
supracondylar fractures and found that the absence of a pulse was the earliest and
most reliable indicator of ischemia. Several studies have shown that early reduc-
tion and pinning of type III supracondylar fractures in children with diminished
or absent pulses will restore the blood flow in the majority of cases. There is a
small percent that do not recover the pulse following reduction, and knowing
when to get an arteriogram or return to the OR for exploration is critical.
Following closed reduction and pinning, immediately reassess the vascular
status. If there is no pulse by palpation or Doppler, you need to determine if the
hand has adequate blood flow. The artery may be in spasm that will resolve with
time; there is a rich collateral circulation that can maintain the viability of the
hand. If there is brisk capillary refill and the hand remains pink and warm,
most surgeons choose to monitor the arm carefully with frequent neurovascular
exams postoperatively.
If the neurovascular status worsens (signs of compartment syndrome, hand is
no longer pink, slowed capillary refill, decreased sensation), immediate inter-
vention should ensue. Initially, this may include angiogram and/or compart-
ment pressure measurements followed by fasciotomy or open exploration with
arterial mobilization (for artery trapped in the fracture site), vessel repair, recon-
struction, or thrombectomy depending on the findings. In the case of isolated
thrombus, urokinase can be attempted for thrombolysis.
Sabharwal recommends angiogram if the pulse does not return within 8-12
hours of appropriate reduction and fixation.
Pitfalls—Supracondylar Fractures
The goal of treatment is safe anatomic reduction and avoidance of residual
varus and extension that are common complications following supracondylar
fractures.
Severe malunion of a supracondylar fracture may lead to a so-called gunstock
deformity, which consists of varus, medial rotation, and extension; (Fig. 8-29)
best visualized by having the patient extend the arms fully and parallel to the
ground. The bony deformity causes a block to motion that cannot be regained
with physical therapy.
 111
Type III Supracondylar Fractures
TECHNIQUE TIPS:
Vascular Assessment and Management

CRPP = closed reduction, percutaneous pinning

NV = neurovascular
112
Elbow—Distal Humerus
A seen a patient, either in residency or practice, with a nonunion, progressive cu-
B
Figure 8-30. A) X-ray showing cubitus
varus of the left elbow secondary to a
prior supracondylar fracture. B) Correc-
tive osteotomy for a gunstock deformity
can be performed if motion is not regained
1 year after healing of a suprcondylar
frature.
A B
Figure 8-31. A) Cartilage hinge intact. B) Articular surface disrupted. C) Complete displacement of lateral condyle.
Corrective osteotomy (Fig. 8-30) for cubitus varus is hard to do well and
should be done only after the elbow has regained mobility, usually at least 1
year after the original fracture. Malunion is obviously more difficult to correct
than to prevent.
The indications for corrective osteotomy are changing now that we under-
stand that cubitus varus predisposes the elbow to subsequent refracture (espe-
cially lateral condyle fractures of the same elbow).
In the past, some referred to the residual deformity as “cosmetic.” We object
to and do not use the term cosmetic in any of children’s orthopedics because
rarely if ever are scientific studies available to document what degree of varia-
tion from normal has functional risks (risk for reinjury, risk for premature
arthritis, inability to pursue a certain type of sport, etc.).
LATERAL CONDYLE FRACTURES
Lateral condyle fractures have a bad reputation with every orthopedist having
bitus valgus, and tardy ulnar nerve palsy (from medial stretch due to progressive
angular deformity). With the development of modern understanding and K-
wire fixation of this injury, the prognosis is in fact quite good for most patients.
For many of the children we treat now, only a few clinic visists are required fol-
lowing pin and cast removal. This section will outline a strategy for predictable
management of this injury.
The mechanism of injury is thought to be a varus force on an extended
elbow with the trochlear ridge on the ulna acting as a fulcrum for avulsion of
the lateral condyle by the lateral ligaments (Fig. 8-31). The bone separates, but
the articular cartilage often remains intact as a hinge making the fracture easier
to reduce (when varus angulation is corrected). However, with a greater angular
force, the cartilage hinge tears, and the fracture displaces. The fragment can dis-
place in the sagittal plane, sometimes rotating nearly 180°.
Classification—Lateral Condyle Fractures
Milch classified lateral condyle fractures based on whether or not the capitellar
ossification center is disrupted by the fracture line. This classification system is
useful for determining prognosis of the fracture or risk of growth arrest; how-
ever, this classification does not help the surgeon develop a treatment plan.
The most common fracture line traverses from the posterolateral metaphysis,
crossing the distal physis, and extending to the unossified trochlea without
C
interrupting the capitellar ossification center. This fracture is referred to as a 113
Milch Type II fracture. Milch Type I fractures are much less common, typically Lateral Condyle Fractures
the fracture begins in the metaphysis, crosses the physis in an oblique fashion,
then traverses the capitellar ossification center. This fracture has a higher risk of
growth arrest as the ossification center is disrupted (Fig. 8-32).

Treatment—Lateral Condyle Fractures

Lateral condyle fractures are intra-articular and cross the distal humeral physis;
they require anatomic reduction both for good joint function and to ensure
normal distal humeral growth. For this reason, most fractures are treated with
open reduction (Fig. 8-33) and K-wire fixation. Some have referred to this as an
“A-O” (always open) fracture. With time and experience, a few minimally dis- Figure 8-32. Milch classification of lateral
placed fractures can safely be treated with casting only. condyle fractures (Type II are the most
Minimally displaced fractures are occasionally seen and can be treated in a common).
long arm cast providing two oblique distal humerus x-rays (in addition to the
AP and lateral views) confirm 2 mm or less of displacement. This rule is of
Pre-op
course a bit arbitrary because x-ray magnification can make one doctor’s 2-mm
measurement seem like 4 mm to another measurer. If non-operative treatment
is chosen, we recommend removing the cast and obtaining AP, lateral, and two
oblique x-rays every week for 3 weeks to ensure that the fracture does not dis-
place in the cast (Fig. 8-34). Once one discovers the tension, time, and energy
required to ensure healing with non-operative treatment, many surgeons choose
k-wire fixation for the borderline case.
Joint surface disruption by a lateral condyle fracture should be anatomically
reduced and fixed with K-wires; this typically requires open reduction for good Post-op
visualization of the joint surface to ensure there is no joint step off or incon-
gruity. Some lateral condyle fractures are displaced on the lateral side but have a
cartilage hinge at the joint surface. Confirmation of intact articular cartilage can
be made with an arthrogram at the time of surgery. If the joint surface is intact,
the reduction can sometimes be obtained in a closed fashion by pushing the
fragment back into place, relying on the hinge for anatomic reduction. The
exact candidates for this variation of treatment are hard to define. Likely the less
experienced surgeon should open and pin all borderline cases until the experi-
ence/judgement titer is optimized. Figure 8-33. Lateral condyle fracture be-
Whether obtained in an open or closed fashion, the reduction should be main- fore and following open reduction and pin
tained with percutaneous smooth K-wires. In all cases, K-wires should be left in fixation.

Pre-op Pre-op Oblique Views After Pinning

Figure 8-34. Displaced lateral condyle fractures are frequently more clearly visualized on the oblique x-rays.This patient was treated with
open reduction and pin fixation.
114
Elbow—Distal Humerus
“Likely the less experienced
surgeon should open and pin
all borderline cases until the
experience/judgement titer is
optimized”
Initial Injury—Minimal Displacement
After 4 weeks in cast
Figure 8-35. Lateral condyle fractures
may displace while in a good cast. It is im-
portant to check x-rays weekly for 3
weeks to ensure alignment is not lost.This
patient seemed to have only a few millime-
ters of displacement (arrow) at the time of
injury. She had late displacement and re-
quired open reduction.
longer than those used for supracondylar fractures because lateral condyle fractures
are usually bathed in synovial fluid, which can delay union and may lead to non-
union. We recommend 4 weeks of immobilization with pins in place followed by
an additional 2-4 weeks of casting or splinting (until callus is visible crossing the
fracture site). Every year we see two or three lateral condyle fractures where the
original treating surgeon (from the infamous “Elsewhere General Hospital”) cor-
rectly diagnosed, reduced, and pinned a lateral condyle fracture but then removed
the pins at 2 or 3 weeks and allowed early motion with subsequent nonunion.
Pitfalls—Lateral Condyle Fractures
The classic severe complication of non-union with late severe cubitus valgus
and tardy ulnar nerve palsy is now almost never seen in developed parts of the
world where early diagnosis and pin stabilization are standard. The most com-
mon problems in advanced centers are now more subtle.
Delayed union (Fig. 8-35) can occur if any gap remains at the fracture site, al-
lowing synovial fluid to track into the fracture line from the joint surface, which
interferes with healing. If the joint line is not well visualized at the time of sur-
gery, or closed treatment plus pinning is attempted, an immediate arthrogram
can be performed to confirm that there is no tracking of dye into the fracture.
Wadsworth has observed that premature growth plate closure may occur,
even in undisplaced fractures. This can lead to a valgus deformity of the elbow
joint requiring later supracondylar osteotomy. Another common problem is cu-
bitus varus due to growth stimulation of the lateral portion of the physis, likely
secondary to increased blood flow in the area of the fracture. This mild defor-
mity is not progressive. Another rare outcome is cubitus varus secondary to
focal physeal closure in the medial one third of the physis (in the fracture type
that extends very medially), despite proper reduction and pinning.
Because the lateral condyle is directly subcutaneous, even with perfect reduc-
tion, the healed lateral condyle fracture commonly results in a “bump” on the
lateral aspect of the elbow. This can be minimized by careful closure of the fas-
cia-muscle layers laterally. This is not a functional problem but some patients
and parents are bothered by the prominence.
The trochlear notch may appear deepened on the AP x-ray following ade-
quate reduction and union, due to focal AVN. The pattern must be recognized
but is rarely treated.
Figure 8-36. Flynn method of treating a lat-
eral condyle nonunion.
 Delayed diagnosis cases occur occasionally—a child presents after several 115
weeks with a displaced fracture of the lateral condyle. Should this be accepted Medial Condyle Fractures
or surgically reduced? The results of surgery are less satisfactory because of the
risk for stiffness and AVN. However, in most cases even up to 6 weeks post in-
jury, we would carefully open the fracture, remove the evolving callus, and pin
the fracture. In cases of significant delay with established nonunion, we advise
Flynn’s method of metaphysis to metaphysis screw fixation above the physis,
which may leave the joint malreduced (Fig. 8-36). This prevents proximal mi-
gration of the condylar fragment and cubitus valgus. The results are not ideal
but are often satisfactory.
In summary, the long-term sequelae of a severely displaced, untreated lateral
condyle fracture is so severe that we usually proceed with surgical stabilization,
no matter how long beyond the original injury. The procedure selected differs
according to the delay (as noted) with the outcome less predictable than in
acutely treated cases.

MEDIAL CONDYLE FRACTURES Figure 8-37. Medial condyle fractures are

Medial condyle fractures (Table 8-6) are very rare (Fig. 8-37). Because it is an rare in children, this fracture was non-dis-
placed and treated with a cast.
intra-articular fracture, a neglected fracture of the medial condyle has the same
poor prognosis as a neglected fracture of the lateral condyle. The medial
condyle or trochlea ossifies between the ages of 7-11 for girls and 8-13 for boys.
The unossified medial condyle in a young child casts no shadow and avulsion is
a matter of conjecture. A common mistake is to confuse a condylar fracture
with an epicondylar fracture because the epicondyle ossifies earlier (between 5
and 9 years). It may be possible to avoid this mistake in children who have soft
tissue swelling on the medial aspect of the joint by examining the elbow under
anesthesia and/or with arthrogram. A condylar fracture is often associated with
valgus instability of the elbow and posteromedial subluxation of the elbow.
If non-operative treatment is chosen, it is important to check x-rays regularly
during the healing process to ensure the fragment does not displace. Similar to
lateral condyle fractures, union may be slow if the fracture is bathed in synovial
fluid, so pins should be left in place 4 weeks, and the elbow casted until good
callus is noted on x-ray.

Table 8-6 Kilfoyle Classification of Medial Condyle Fractures

Type I Type II Type III

Extends from medial Extends into medial Condylar fragment is

condylar metaphysis to condylar physis but is rotated and displaced
physis (not into the joint) minimally displaced
Cast Closed reduction and Open reduction and
pin fixation pin fixation
116 Pitfalls—Medial Condyle Fractures
Elbow—Distal Humerus
Failure to recognize a displaced medial condyle fracture can lead to nonunion
and cubitus varus. AVN can occur if the blood supply to the trochlea is dis-
rupted either by dissection or by the original trauma.

MEDIAL EPICONDYLE FRACTURES

The medial epicondyle of the distal humerus ossifies between the ages of 5 and
9 years and can be avulsed by valgus stress and contraction of the flexor muscles
(Table 8-7). We frequently see this injury in young gymnasts and baseball
pitchers; this can be an acute on chronic injury or a single acute injury. Trau-
matic elbow dislocation is often accompanied by medial epicondyle fracture;
the bony fragment can become entrapped in the joint. In children younger than
the age of 9, the clinical signs of hematoma may be more obvious than the radi-
ographic ones. If the epicondyle is ossified, a film of the opposite elbow may
help to clarify the normal position of the epicondyle. The degree of displace-
ment should be assessed and the presence of other injuries noted, such as frac-
ture of the radial neck and injury of the ulnar nerve that lies close by.

Treatment—Medial Epicondyle Fractures

Indications for displaced fractures remain empiric because there have been no
good studies comparing long-term outcome of operative and non-operative
treatment of medial epicondyle fractures. If the fracture has minimal displace-
ment (less than 5 mm in any plane) and minimal soft tissue swelling, cast im-

Table 8-7 Classification—Medial Epicondyle Fractures

Minimally Displaced Rotated Trapped Dislocated
mobilization alone can be considered. X-rays should be checked during early 117
healing to ensure that there has been no further displacement. Medial Epicondyle Fractures
If a medial epicondyle fracture is allowed to heal in a significantly displaced
position, the flexor-pronator origin is moved distally and laterally. Theoretically,
this may lead to elbow weakness or valgus instabilty; therefore many surgeons
At Injury
now advise anatomic reduction and internal fixation of displaced fractures.
It is often difficult to establish the true fragment displacement on plain radi-
ographs, and there is significant debate as to the amount of displacement that is
acceptable for normal elbow function with a medial epicondyle fracture. If
there is any question, the elbow can be tested under anesthesia. If the elbow is
found to be unstable, open reduction and fixation is preferred. In general, if the
fracture fragment is displaced more than 5 mm, we perform surgical reduction
especially in athletic patients (Fig. 8-38).
If the child presents with a dislocated elbow and a medial epicondyle frac-
ture, the elbow should be emergently reduced to assist the circulation and re-
lieve pain. If the medial epicondyle remains trapped in the joint during the re-
duction, it can sometimes be extricated by applying a valgus stress and After Open Reduction
supinating the elbow; however, the fragment rarely returns to its bed. Open re-
duction should be performed in these cases.
For open reduction, the patient can be positioned supine with the arm exter-
nally rotated on an arm board or prone with the arm in a half-Nelson position
(behind the back). A small incision is centered at the level of the bed of the epi-
condyle in line with the posterior border of the humerus (remember that the
medial epicondyle is posterior on the humerus). Hematoma is usually encoun- Figure 8-38. Medial epicondyle fractures
tered just under the subcutaneous fat and leads to the fracture bed. that are significantly displaced are typically
The ulnar nerve must be identified through the posterior periosteum and treated with open reduction and internal
protected. The nerve does not need to be dissected out; temporary nerve palsy fixation.
can result from overelaborate display of the nerve, but it should be palpated and
identified.
The fragment with the flexor-pronator origin can then be milked proximally
up into the incision with the forearm pronated to relax the volar musculature.
Now the orientation can be visually determined and the fragment replaced into
its anatomic position. A towel clip will secure the reduction while fixation is “There is significant debate
placed.
In younger children, a smooth K-wire can maintain the reduction with a few
as to the amount of
sutures in the periosteum. In older children ("6 years), the medial epicondyle displacement that is
can be fixed with a single cancellous screw starting in the fragment and contin- acceptable for normal elbow
uing up the medial column of the distal humerus. Postoperatively, the patient is
casted at 90° of elbow flexion and pronation to relax the flexor-pronator group function with a medial
for 3-4 weeks and then range of motion is begun. epicondyle fracture”

A B C

Figure 8-39. A) An elbow dislocation with medial epicondyle fracture. B) Trapped medial epicondyle following reduction. C) Emergent re-
duction and fixation.
118 Pitfalls—Medial Epicondyle Fractures
Elbow—Distal Humerus
Missing a medial epicondyle that is entrapped in the joint can lead to signifi-
cant loss of motion and disability (Fig. 8-39).
The ulnar nerve may be irritated or stretched at the time of injury, reduction, or
surgery; this ulnar neuropathy is usually transient. Some patients develop a late
ulnar neuritis, likely secondary to irritation by callus or a chronic valgus instability.
Nonunion is common in displaced fractures treated non-operatively; how-
ever, this rarely leads to clinical problems (with the possible exception of late
ulnar neuritis).
Even with anatomic healing, the elbow may become stiff following healing of
a medial epicondyle fracture, so early motion is recommended by most surgeons.

LATERAL EPICONDYLE FRACTURES

Figure 8-40. As the lateral epicondyle
begins to ossify (arrow), it is frequently
mistaken for a fracture.This picture repre-
sents a normal elbow in an 11-year-old girl.
The center for the lateral epicondyle ossifies late (age 8-13) and is often irregu-
lar, causing beginners to confuse it with a fracture (Fig. 8-40). The extensor
muscles originate on the lateral epicondyle and may be responsible for avulsion
injuries. Very few true fractures of lateral epicondyle are seen; therefore there is
no consensus on the need for or type of treatment. Minimally displaced frac-
tures can be casted for 4-6 weeks.

SUMMARY
Distal humerus fractures come in many varieties that change as the child grows
and growth centers appear. Treatment options vary based on the type of fracture
and age of the patient. It is important not only to understand each fracture and
its associated complications, but to have a thorough knowledge of normal
elbow development and anatomy to be able to return each child to the best
function possible.

Suggested Readings
Benesahel, H. et. al. Fractures of the Medial
Condyle of the Humerus in Children. J of
Pediatric Orthopedics, 6:430-433, 1986.
Blount WP. Fractures in children. Williams
and Wilkins 1955.
Campbell CC, Waters PM, Emans JB,
Kasser JR, Millis MB. Neurovascular in-
jury and displacement in type III supra-
condylar humerus fractures. J Pediatr Or-
thop. 1995 Jan-Feb;15(1):47-52.
Cramer KE, Green NE, Devito DP. Inci-
dence of anterior interosseous nerve palsy
in supracondylar humerus fractures in
children. J Pediatr Orthop. 1993 Jul-
Aug;13(4):502-5.
Culp RW, Osterman AL, Davidson RS, Skir-
ven T, Bora FW Jr. Neural injuries associ-
ated with supracondylar fractures of the
humerus in children. J Bone Joint Surg
Am. 1990 Sep;72(8):1211-5.
Davids JR, Maguire MF, Mubarak SJ,
Wenger DR. Lateral condylar fracture of
the humerus following posttraumatic cu-
bitus varus. J Pediatr Orthop. 1994 Jul-
Aug;14(4):466-70.
Delee, JC, et al. Fracture-separation of the dis-
tal humerus epiphysis. JBJS 1980; 62:4-51.
Flynn JC, Richards JF Jr. Non-union of mini-
mally displaced fractures of the lateral
condyle of the humerus in children. J Bone
Joint Surg Am. 1971 Sep;53(6):1096-101.
Gillingham BL, Rang M. Advances in chil-
dren’s elbow fractures. J Pediatr Orthop.
1995 Jul-Aug;15(4):419-21.
Haraldson S. Osteochondrosis deformans ju-
venelis capituli humeri including investi-
gation of the intra-osseous vasculare in
the distal humerus. Acta Orthop Scand.
[suppl], 38. 1959.
Kilfoyle RM. Fractures of the medial condyle
and epicondyle of the elbow in children.
Clin. Orthop. 1965 July-Aug;41:43-50.
Kim HT, Song MB, Conjares JN, Yoo CI.
Trochlear deformity occurring after distal
humeral fractures: magnetic resonance im-
aging and its natural progression. J Pediatr
Orthop. 2002 Mar-Apr;22(2):188-93.
Lee SS, Mahar AT, Miesen D, Newton
PO. Displaced pediatric supracondylar
humerus fractures: biomechanical analysis
of percutaneous pinning techniques. J Pe-
diatr Orthop. 2002 Jul-Aug;22(4):440-3.
Mohammad S, Rymaszewski LA, Runciman
J. The Baumann angle in supracondylar
fractures of the distal humerus in chil-
dren. J Pediatr Orthop. 1999 Jan-
Feb;19(1):65-9.
Mubarak SJ, Carroll NC. Volkman’s contrac-
ture in children: Aetiology and preven-
tion. J Bone Joint Surg Br. 1979 Aug;61-
B(3):285-93.
Reitman RD, Waters P, Millis M. Open reduc-
tion and internal fixation for supracondylar
humerus fractures in children. J Pediatr
Orthop. 2001 Mar-Apr;21(2):157-61.
Sabharwal S, Tredwell SJ, Beauchamp RD,
Mackenzie WG, Jakubec DM, Cairns R,
LeBlanc JG. Management of pulseless
pink hand in pediatric supracondylar
fractures of humerus. J Pediatr Orthop.
1997 May-Jun;17(3):303-10.
Skaggs DL, Mirzayan R. The posterior fat
pad sign in association with occult frac-
ture of the elbow in children. J Bone Joint
Surg Am. 1999 Oct;81(10):1429-33.
Skaggs DL, Cluck MW, Mostofi A, Flynn
JM, Kay RM. Lateral entry pin fixation
in the management of supracondylar
fractures in children. JBJS Am. 2004
Apr;86-A(4):702-7.
 Elbow—Proximal
9
Radius and Ulna
Maya Pring m Dennis Wenger m Mercer Rang

• Pulled Elbow 121

• Elbow Dislocation 122
• Radial Head and Neck Fractures 124
• Olecranon Fractures 128
• Coronoid Fractures 130
• Monteggia Fracture/Dislocation 131

INTRODUCTION
In the last edition, all fractures about the elbow were presented in a single dose. Ad-
“What does not
vancement in orthopedic knowledge and further understanding of the remarkable
variety of children’s elbow injuries makes this a less viable option now. With the in-
destroy me, makes
creased participation in “extreme sports” we have noted a marked increase in previ- me stronger”
ously less common elbow injuries in children including radial head fractures and
injuries to the coronoid process. Placing the entire spectrum of elbow fractures in a —NEITZSCHE
single chapter would make it very long and we hope that our arbitrary separation
into distal humerus and proximal forearm segments will not confuse the reader.

Anatomy
The elbow joint does not have inherent bony stability; the collateral ligaments
and capsule serve as the major joint stabilizers (Fig. 9-1). The collateral liga-
ments connect the distal humerus to the ulna, the annular ligament
119
120
Elbow—Proximal Radius and Ulna
Figure 9-1. The capsule and ligaments
give stability to the elbow.
Figure 9-2. Cross section at the level of
the elbow.
Figure 9-3. Examining an injured child
can be very difficult.
maintains the radioulnar joint, and the interosseuos membrane helps to main-
tain the spatial relationship between the radius and ulna.
The brachial artery, median nerve, and radial nerve all coursing anterior to
the elbow joint are at risk for stretch injury with a proximal forearm fracture or
elbow dislocation. The ulnar nerve, running medially just behind the medial
epicondyle, may be stretched, torn, or entrapped in the joint at the time of in-
jury or during reduction. The posterior interosseous nerve, coursing anterior to
the radial head and anterolateral to the radial neck, can easily be injured when
the proximal radius is fractured or dislocated (Fig. 9-2).
Initial Exam
As discussed in the prior chapter, it can sometimes be difficult to distinguish be-
tween an injured and an infected elbow in a young child. Be wary in puzzling
cases and order a complete blood count (CBC), sedimentation rate, and C-reac-
tive protein when the etiology of joint swelling is unclear.
Once the area of concern is identified, a skin exam will rule out an open frac-
ture, with the standard neurovascular exam then performed (see Chapter 8 for
details). The fracture type can sometimes be estimated by gentle palpation;
however, this may be difficult or impossible in an uncomfortable young child
with a swollen elbow (Fig. 9-3).
Because additional fractures in the same limb are common, always check the
joint above and below the area of concern. The contralateral elbow should be
examined to determine the normal anatomy and motion for each individual.
Radiographic Issues
Radiographs of the flexed elbow often represent compromise views of the upper
forearm and the distal humerus but are the usual starting point. Well-centered
AP and lateral views of the proximal forearm and distal humerus may be re-
quired to better identify a puzzling fracture. Also, an accurate assessment of an-
gulation and shift can only be measured on films taken at right angles to the
plane of fracture angulation.
As previously discussed, a fat pad or “sail” sign may be the only x-ray indica-
tion of a pediatric elbow fracture. The actual location of these occult fractures is
often not determined until follow-up x-rays show callus formation. Olecranon
and radial neck fractures are the most common occult fractures of the proximal
forearm (supracondylar fracture most common in the distal humerus).
Plastic deformation or greenstick fractures of the ulna (and occasionally the
radius) may cause a radial head dislocation, so it is important to obtain x-rays of
the entire forearm including the wrist and elbow when there is a forearm frac-
ture. A line drawn down the center of the proximal radial shaft should pass
Figure 9-4. The radial head should point
directly at the capitellum on both the AP and Figure 9-5. Note subtle anterior subluxa-
lateral views. tion of the radial head.
through the center of the ossification center of the capitellum on both AP and 121
lateral views (Fig. 9-4); if not, the radial head is subluxed or dislocated and Pulled Elbow Syndrome
must be reduced (Fig. 9-5).

PULLED ELBOW SYNDROME

(NURSEMAID’S ELBOW)
A pulled elbow is a common early childhood injury. The clinical picture is char-
acteristic; a child between 1 and 4 years suddenly refuses to move an arm and
holds the elbow slightly flexed with the forearm pronated. Often, parents think
the arm is paralyzed or broken and they rarely mention that the problem began
as the child was pulled along or lifted by the wrist—the usual cause in our fast-
paced culture (Fig. 9-6). It is remarkable that not all children experience a
pulled elbow!
Although a pulled elbow can be readily diagnosed and treated once you have
learned to recognize it, do not get lulled into a false sense of security, forgetting
to consider other problems. The diagnosis of nursemaid’s elbow is now well rec-
Figure 9-6. The usual mechanism of radial
ognized by most primary care providers and is sometimes overdiagnosed. Un- head subluxation in a fast-paced culture.
fortunately, some children with other diagnoses end up having painful “pulled
elbow” reduction attempts. Conditions that we have had referred to our clinic “Unfortunately, some
that were initially treated as a pulled elbow include:
children with other diagnoses
! Septic elbow
! Olecranon fracture end up having painful
! Radial head or neck fractures (Fig. 9-7) ‘pulled elbow’ reduction
! Supracondylar fracture
! Septic wrist
attempts”
Pulled elbow should be a diagnosis of exclusion. In each of the above cases, one Initial Visit 3 weeks later
or even several reduction attempts had been carried out (unsuccessfully of
course). When you encounter the child in this circumstance, the ability to clar-
ify the diagnosis without further terrifying the child defines the art of children’s
orthopedics. As a “true expert,” you may have to once again attempt a reduc-
tion, even though less specialized experts have already tried. This is a very tricky
environment.
For a true pulled elbow, the x-rays are usually normal. Occasionally, a very
slight lateral or distal shift of the radial head can be seen. Ultrasound has been
reported to be useful in confirming the diagnosis; however, we have no experi-
ence with this technique (Kosuwon).
A B
Salter and Zaltz found that when longitudinal traction is applied to the arm
(with the forearm in pronation) the annular ligament partially tears at its at- Figure 9-7. We often see masqueraders
tachment to the radius, allowing the radius to move distally, slipping under the of a pulled elbow. A) This patient had a ra-
dial neck fracture, which was thought to be
annular ligament. When traction is released, the ligament is carried up and be-
a pulled elbow. B) Callus was noted on
comes impacted between the radius and capitellum (Fig. 9-8). After the age of 5 follow-up x-ray.
years, the attachment of the annular ligament to the neck of the radius strength-
ens and prevents displacement and radial head subluxation. Enlargement of the
proximal radial epiphysis with growth may also improve stability.

Treatment—Pulled Elbow
Fortuitous reduction can occur when the x-ray technician supinates the arm to
obtain an AP x-ray. Because the x-rays are usually normal, you must rely on the
history and your exam to reach the diagnosis. In simple cases, reduction is easy:
supinate the flexed elbow and you will feel a click as the subluxed radial head re- Figure 9-8. With longitudinal traction the
duces. Often, the elbow must be flexed above 90° with firm supination to annular ligament can partially tear allowing
achieve reduction. Producing and feeling the click that accompanies successful the radial head to move distally.
122
Elbow—Proximal Radius and Ulna
Figure 9-9. For recurrent nursemaid’s el-
bows, we sometimes use a cast in supina-
tion and flexion for 3 weeks. This type of
cast can also be used in a case where you
do not feel the reduction click and the x-
rays are normal.
AP
Lateral
Figure 9-10. Elbow dislocations are
usually accompanied by a fracture—
Note the medial epicondyle trapped in
the joint (arrow).
reduction of the annular ligament can be compared to feeling an Ortolani posi-
tive hip reduce for the first time; several successful reductions are required to
feel confident of your technique.
After the typical reduction, the child often stops crying, seems more com-
fortable, and starts to move the arm within a minute or two. No immobiliza-
tion is required, but the parents should avoid pulling the child or lifting by the
arm for the next several years.
Recurrence is relatively common and a child may have repeated subluxations
in the first 3-4 years of life. Repeat injuries are treated in the same fashion as
first-time subluxations, with the problem gradually disappearing by age 5 years;
the younger the child, the greater the risk for recurrent subluxation. Recur-
rences do not produce long-term problems. In a child with multiple recur-
rences, we sometimes cast for 3 weeks in the reduced position (elbow flexed to
100° with the forearm supinated), allowing the enforced rest and temporary
joint stiffness to add stability (Fig. 9-9).
Pitfalls—Pulled Elbow
A few times a year one is faced with a case that does not seem to reduce despite
a correct reduction maneuver by an experienced treater. Clearly, the differential
diagnosis noted previously is considered. When convinced that we have a true
unreducible nursemaid’s elbow (not an occult septic elbow or fracture), our ap-
proach includes casting the child in a position that technically will reduce the
subluxation (elbow flexed to 100°, full supination) for 3 weeks. This usually
solves the problem.
There have been a few case reports in the literature of pulled elbows that
were completely irreducible with closed means. In these cases, surgical explo-
ration demonstrated that the annular ligament had slipped past the equator of
the radial head and become trapped in the radiocapitellar joint.
DISLOCATIONS—ELBOW JOINT
In children, elbow dislocations without a fracture are uncommon. Whenever
you encounter an elbow dislocation, assume an associated occult fracture (which
may prevent reduction). The most common example is a medial epicondyle frac-
ture, which frequently becomes entrapped in the joint. A non-concentric reduc-
tion should alert the examiner to a trapped fragment, which may be cartilage in
younger children (the medial epicondyle ossifies around age 7) or bone in the
adolescent (Fig. 9-10). Contralateral films for comparison are critical.
The articular surface of the ulna and of the capitellum may also fracture and
prevent concentric reduction. A flap of articular cartilage and subchondral bone
lifted off the articular surface may be barely perceptible on the x-ray. Crepitus
and a restricted range of motion following reduction should alert you to possi-
ble osteochondral fragments in the joint.
More obvious fractures associated with elbow dislocation include lateral
condyle, olecranon, and radial neck injuries; these are easily identified on x-ray
and are more straightforward in terms of management.
Also, dislocation gives risk to the neurovascular structures, muscles, collateral
ligaments, and capsule.
Classification—Elbow Dislocations
Elbow dislocations are described by the position of the radius and ulna in relation
to the distal humerus (anterior, posterior, medial, or lateral). They are further
classified based on whether or not the proximal radioulnar joint remains intact 123
(Table 9-1). Posterolateral dislocations, by far the most common in reported se- Dislocations—Elbow Joint
ries, are thought to be caused by a fall on the outstretched hand with the elbow
extended and abducted. Typically, the radioulnar articulation remains intact with
only rare instances of divergent dislocation (radius and ulna separated).

Treatment—Elbow Dislocations
The dislocation should be reduced as soon as possible to relieve pain and im- “Failure to recognize an
prove circulation. Conscious sedation helps to relax the muscles adequately for entrapped fragment in the
an atraumatic reduction. An easy method for reduction includes placing the
child prone with the elbow flexed over the edge of the bed so that the forearm joint can lead to destruction
hangs vertically downward. When the child relaxes, a little pressure over the ole- of the articular cartilage,
cranon with correction of any sideways displacement usually reduces the elbow.
This is a gentle maneuver that does not require the force required for some
non-concentric wear and
orthopedic reductions. Avoid hyperextending the elbow prior to reduction be- early osteoarthritis”
cause this may further injure the brachialis and neurovascular structures anteri-
orly. Immediate pain relief can be expected. The child is typically casted for 2-3
weeks to allow soft tissue healing and to avoid the slight risk of recurrent dislo-
cation. Casting longer than 3 weeks should be avoided because the risk of stiff-
ness increases with time in the cast.
Immediate postreduction x-rays should be performed to assess reduction and
look for the medial epicondyle. If the medial epicondyle is separated and out-
side the joint, it can be treated by casting alone if minimally displaced. If
markedly displaced, it should be surgically reduced within a few days. If
trapped in the joint, prompt open reduction is required.

Pitfalls—Elbow Dislocation
Failure to recognize an entrapped fragment in the joint can lead to destruction
of the articular cartilage, non-concentric wear, and early osteoarthritis. In the
rare cases of dislocation without fracture, the collateral ligaments of the elbow
may be disrupted and even in children this can occasionally lead to instability
and require reconstruction.
Nerves and vessels may be stretched and develop a temporary palsy or spasm
but most resolve with time. However, neurovascular entrapment following re-

Table 9-1 Classification—Elbow Dislocation

Type I Type II
Proximal radioulnar Proximal radioulnar joint disrupted
joint intact

Most common—posterior Anteroposterior Mediolateral (transverse) Radioulnar translocation

Can also dislocate anteriorly, divergent divergent
laterally, or medially
124
Elbow—Proximal Radius and Ulna
Following Reduction of Dislocation
A
Non-concentric Reduction
B
After Open Reduction
C
After Open Reduction
D from that of the shaft, creating a cam-type deformity that inhibits pronation
Figure 9-11. A, B) Child with elbow dis-
location reduced elsewhere and referred
to us for ulnar nerve palsy. The lateral
view suggests non-concentric reduction.
C, D) After open reduction, which re-
vealed the unlar nerve was trapped in the
joint and was blocking reduction.
Figure 9-12. Skateboarding down the
rails of steps. The new generation en-
sures that orthopedists will keep busy.
(Photo courtesy of T. Hooker.)
duction can lead to disability if not noted and treated promptly. Entrapment of
the ulnar nerve is most common with radial and median nerve entrapment oc-
curing occasionally. It may be very difficult to determine if the nerve was only
stretched or if it is truly trapped in the joint. A slightly non-concentric reduc-
tion on x-ray should alert one to the possibility of soft tissue entrapment that
requires surgical intervention (Fig. 9-11).
Heterotopic ossification can develop in the ligaments and capsule following
injury, but usually does not cause disability. In rare cases, myositis ossificans de-
velops in the muscles surrounding the elbow, leading to significant loss of joint
motion.
PROXIMAL RADIUS:
RADIAL HEAD AND NECK FRACTURES
In the previous edition of this book, we noted that children get radial neck frac-
tures and adults get radial head fractures. This circumstance has changed with
the adolescent and teenage trends toward participation in extreme sports. We
now frequently see radial head as well as radial neck fractures in skateboarders,
ATV riders, and other children that participate in high-speed, high-risk sports
(Fig. 9-12).
The majority of these fractures are due to a valgus force; some associated with
a posterior dislocation; and the remainder accompanied by fractures of the ulnar
shaft, reminiscent of a Monteggia fracture. Other fractures around the elbow are
present in nearly half of the children with displaced radial neck fractures; look
carefully for associated olecranon, coronoid, or distal humerus fractures.
Because the annular ligament holds the radial metaphysis to the shaft of the
ulna, when the neck is fractured, the displaced radial head is not only angulated
but also shifted laterally as the shaft shifts medially. Pronation and supination
depend on the relationship of the radial head to the capitellum and ulna. Signif-
icant translation of the radial head separates the center of rotation of the head
and supination (Fig. 9-13). No available study clarifies how much pure transla-
tion is acceptable for later elbow function; therefore we try to minimize transla-
tion and do not accept more than 2-3 mm in any direction.
The cartilaginous head of the radius fits the metaphysis like a bottlecap. For
this reason, the majority of fractures are metaphyseal, only a few are epiphyseal
separations. Epiphyseal separations, when they occur, put the radial head at risk
for osteonecrosis because the blood supply is disrupted [the blood supply as-
cends from a distal source, similar to that of the femoral head, thus each has
high risk for avascular necrosis (AVN)]. The usual level of injury through the
Ulna Ulna
Radial Head
Shaft Shaft
Radial Head
Figure 9-13. If the radial head is not centered on the shaft, pronation and supination will be
affected.
metaphysis is just distal to the entry of the vessels, but the blood supply may 125
still be disrupted with significant displacement. Proximal Radius:
Radial Head and Neck Fractures

Classification—Radial Head and Neck Fractures

Radial Neck Angulation
Radial neck fractures can be angulated, translocated, or completely dislocated
(Table 9-2). With high-level sports and repetitive motions such as pitching or
gymnastics, stress injuries are becoming more common. Rarely, repetitive com-
pressive forces to the radial head and neck may cause osteochondritis dissecans
at the joint surface or may injure the physis, creating an angular deformity of
the radial neck.

Treatment—Radial Head and Neck Fractures

Figure 9-14. Radial neck fractures with less
Tilt of the radial head is better tolerated than translation. Therefore minimally than 30° of angulation can be casted. With
angulated fractures (up to 30°) do not need to be reduced as they will remodel angulation !60°, reduction must be per-
with growth (Fig. 9-14). We usually protect the elbow in a long arm cast for formed. Between 30° and 60° there is some
debate as to when reduction is necessary.
three weeks followed by encouragement of early motion.
For moderately angulated fractures (30°-60°), we try manipulation in the
emergency room under conscious sedation. More severely angulated fractures At Injury Post Reduction
(!60°) are ideally reduced in the operating room with facilities available for
open reduction if this is found to be necessary (Fig. 9-15).
Several published methods for closed radial head reduction are reviewed in
the following technique tips. Knowledge of each method may save you from
opening a radial neck fracture, which increases the risk for elbow stiffness or, at
worst, AVN of the radial head. Because of these risks, several of these methods
should be attempted before proceeding to open reduction.
If the radial head cannot be reduced to less than 30° of the normal position, a
percutaneous pin (under image intensifier guidance) can often be used to lever Figure 9-15. Child with radial neck frac-
the head back on to the shaft (Fig. 9-16). Gentle pronation and supination with ture treated by Esmarch bandage method
direct thumb pressure on the radial head may then improve translation. of closed reduction.

Table 9-2 Classification—Radial Head and Neck Fractures

(adapted from Rockwood and Wilkins)
I.Valgus Fractures II. Fractures Secondary to Dislocation

A. SALTER-HARRIS I OR II D. REDUCTION INJURY

B. SALTER-HARRIS IV

E. DISLOCATION INJURY

C. FRACTURE OF THE METAPHYSIS

126
Elbow—Proximal Radius and Ulna
Blunt end—
Steiman pin
After Reduction
Figure 9-16. A K-wire or Steinmann pin
can be used as a joystick for percutaneous/
closed reduction.
Figure 9-17. If the reduction is found to
be unstable, it can be secured with percu-
taneus K-wires, taking care to avoid the ar-
ticular surface.
Figure 9-18. Screws and K-wires may be neccesary to fix an intra-articular radial head fracture. These should be inserted through “safe
zone” described by Smith and Hotchkiss. (Illustration based on Smith and Hotchkiss.)
Johann Friedrich August von Esmarch
1823-1908
A German military surgeon who was concerned with
blood loss and first aid. During the insurrection against
Denmark in 1848-1850, he organized the resistance move-
ment. In 1857 he became Professor of Surgery at Kiel, suc-
ceeding Stromeyer, the tenotomist, and marrying his
daughter. In 1871 he became Surgeon General of the army
and published his description of the bandage that bears his
name. He used this to produce a clear, bloodless field for
surgery and to diminish the blood loss during amputations
in particular.
Occasionally, the radial head can be reduced to the capitellum, but the radial
shaft still sits medially preventing normal pronation and supination. Wallace de-
scribed a novel percutaneous technique for reducing the ulnar translation of the
radial shaft to the radial head. A small incision is made on the posterior surface
of the proximal forearm at the head of the bicipital tuberosity and a blunt-tipped
elevator (“Joker”) is passed between the radius and ulna. The radius can then be
gently levered laterally while maintaining the position of the radial head with the
thumb. The reduction may be stable or can be fixed with a percutaneous K-wire.
There have been no reports of AVN or synostosis with this technique.
If attempts at closed reduction and percutaneous reduction fail to give ade-
quate alignment, open reduction should be carried out because late corrective
surgery for malunion of the radial neck is very difficult. Vostal showed that the
annular ligament or capsule occasionally gets trapped in the fracture, which
prevents closed reduction. For open reduction, the Kocher approach is used:
The elbow joint is entered laterally between the extensor carpi ulnaris and an-
coneus. The dissection is kept above the annular ligament and the arm pronated
throughout the procedure to protect the posterior interosseous nerve.
The joint is inspected and if any soft tissue remains attached to the radial
head, extreme caution should be used to maintain them to protect the blood
supply. The radial head can then be manually placed on the shaft. Occasionally,
the annular ligament may need to be repaired. Stability should be checked with
pronation and supination while directly visualizing the reduction.
Once reduced, these fractures are often stable and do not require internal fix-
ation. If instability is noted intraoperatively, one or two smooth K-wires can be
inserted from the lateral proximal radius, just lateral to the articular cartilage,
crossing the fracture and engaging the medial metaphyseal or diaphy-seal cortex
(Fig. 9-17). The pin should not enter the humerus or cross the radiocapitellar
 127
TECHNIQUE TIPS: Proximal Radius:
Radial Head and Neck Fractures
Radial Neck Fracture Reduction

1
The Columbus (Ohio) technique. Neher and Torch
have described a technique of closed reduction that
requires two people to manipulate the head back
onto the shaft.A varus force is maintained and the ra-
dial shaft is pushed laterally while the radial head is
pushed back onto the shaft. (Drawing based on
Neher and Torch, see Suggested Readings.)

An Esmarch bandage can be wraped tightly from dis-

tal to proximal. The soft tissues help push the radial
head back into place (Fig. 9-15).

A K-wire or Steinmann pin can be used as a joystick

to aid in closed reduction (also see Fig. 9-16).

The modified percutaneous technique described by

Wallace utilizes a joker between the radius and ulna
to lateralize the radial shaft while the radial head is
reduced by thumb pressure or K-wire.
(Method or Wallace et al. Children’s Hospital—San
Diego Treatment outcome of radial neck fractures in
children and introduction of a new reduction tech-
nique. POSNA—Jacksonville, May 2003.)
128
Elbow—Proximal Radius and Ulna
Figure 9-19. Cubitus valgus following a
left radial neck fracture with physeal clo-
sure (proximal radius), which occured at a
young age.
Figure 9-20. This is a normal elbow, the
irregular apophysis is often mistaken for a
fracture.
joint. Motion should be avoided while the pin is in place with the pin removed
early (3 weeks is the maximum).
Intra-articular radial head fractures may require open reduction and internal
fixation to maintain joint congruity (gap or intra-articular step off of more than
2 mm) CT scans may be needed to accurately assess displacement. The postero-
lateral or Kocher approach is used to expose the radial head. Fragments need to
be fixed anatomically. Screws and/or K-wires can safely be inserted through the
safe zone described by Smith and Hotchkiss (Fig. 9-18).
In the past, some authors advocated excision of the radial head for commin-
uted fractures. In growing children, this should be avoided to prevent migration
of the radius proximally, which destabilizes the distal radioulnar joint and can
cause wrist and elbow pain.
Pitfalls—Radial Head and Neck Fractures
Eventual full flexion and extension of the elbow can be expected in most cases,
but some loss of rotation is common. Imperfect results are more common in
patients following surgery than in conservatively treated cases; Rang noted a
higher correlation with the method of treatment than with the severity of in-
jury. The lesson to be learned is that you should not give up on closed reduction
until you have tried every trick you know.
Although rare, synostosis is a hazard on occasion even with closed reduc-
tion. The clearance between the proximal radius and ulna is small, and the
torn periosteum may create a bridge that allows cross union between the two
bones. Not only does synostosis block rotation but it may result in cubitus val-
gus. Heterotopic ossification may develop following open reduction of radial
neck fractures (often seen in the vicinity of the biceps tendon) and correlates
with loss of rotation.
Part or all of the radial head may develop AVN. Irregularity of the head and
premature closure of the growth plate are common. The carrying angle is often
increased in children due to premature physis closure (Fig. 9-19).
Nonunion is rare but disastrous. This may be due to closed reduction where
the head is relocated upside down so that the articular cartilage prevents heal-
ing. Even if the head is correctly positioned, periosteal interposition may pre-
vent adequate healing.
PROXIMAL ULNA:
OLECRANON FRACTURES
The child’s olecranon structure differs from an adult with more spongy bone,
making the fracture line more difficult to identify. The layer of articular carti-
lage is thick, allowing occasional osteochondral fractures. The proximal epiph-
ysis (appears at age 8 in girls, 10 in boys) is often irregular and although rarely
separated, often is interpreted by primary care givers as a fracture (as in many
other instances, a contralateral lateral x-ray may help clarify this, Fig. 9-20).
Although solitary fractures of the olecranon are seen, the majority are associ-
ated with fractures or dislocations of the radial neck.
Classification—Olecranon Fractures
Pediatric olecranon fractures are classified as noted in Table 9-3. Adolescent and
adult fractures have been classified by Morrey as comminuted or non-commin-
uted. Oblique fractures and longitudinal split fractures are as common as trans-
verse fractures.
Treatment—Olecranon Fractures 129
Proximal Ulna: Olecranon Fractures
The majority of pediatric olecranon fractures are undisplaced and require only a
cast. A cast in extension will reduce the pull of the triceps. When the perios-
teum is torn, the fragments may separate; therefore if the fracture does not re- At Injury
duce by extending the elbow, there may be interposed periosteum or bone frag-
ments that require open reduction to realign the joint surface.
Displaced fractures are treated with open reduction and internal fixation.
The incision should be made just lateral to the subcutaneous border of the
proximal ulna and should stay lateral to the tip of the olecranon (avoid putting
incisions directly over any subcutaneous bone or in an area that will frequently
experience pressure). Keeping the incision a little lateral allows a soft tissue layer
between the incision and the bony prominence of the olecranon.
Once the fracture is irrigated with any interposed bone fragments removed,
Post Fixation
most fractures easily reduce with elbow extension and can be held with a towel
clip while fixation is placed. The joint should be checked through a small lateral
arthrotomy to ensure a smooth joint surface with no step offs or gaps; this also
allows the joint to be irrigated to avoid leaving loose bodies that could further
damage the articular surface. Two smooth K-wires and a tension band wire
technique provide excellent fixation of the fracture fragments (Fig. 9-21).
The pins should be buried under the skin and left in place until the fracture is
completely healed. Percutaneous pins do not supply adequate fixation against
the pull of the triceps muscle. Sutures have been suggested (rather than wires) for Figure 9-21. Displaced olecranon frac-
the tension band, but they are more likely to allow loss of reduction (Fig. 9-22). tures are best treated with ORIF. This
shows the classic fixation with two K-
wires and a tension band.

Pre-operative x-ray Intra-operative x-ray X-ray taken 1 hour later

Figure 9-22. Some young children can be treated with K-wires and a suture tension band. However, this x-ray is a good example of what
can occur if the child is stronger than the suture. The x-ray taken 1 hour later shows a 2-cm separation due to pull of the triceps. Wire
should be used in bigger elbows. See Figure 9-21 for final fixation.

Table 9-3 Classification—Pediatric Olecranon Fractures

Type I Type II Type III

Apophysitis Incomplete stress fracture Complete fracture

—Apophyseal avulsion
—Apophyseal metaphyseal combination
130
Elbow—Proximal Radius and Ulna
At Injury
After Open Reduction
Figure 9-23. Type III coronoid fracture
partially hidden by the radial head in this x-
ray (indicated by the arrow) resulted in in-
stability of the elbow and was treated with
open reduction and suture anchor fixation.
Table 9-4 Regan and Morrey Classification—Coronoid Fractures
Type I
Avulsion of the tip of the coronoid
For more comminuted fractures, a contoured plate and screws often gives
better fixation. A 1/3 tubular plate can easily be contoured to the olecranon,
and pre-contoured plates are also available for near adult size patients.
Pitfalls—Olecranon Fractures
Comminution at the joint surface, or joint malreduction may lead to early arthri-
tis. The pull of the triceps tends to pull olecranon fractures apart, especially if
casted in flexion; this can lead to poor motion and function because of malreduc-
tion. There are reports of nonunion, but this is rare in children. Transient neuro-
praxia of the ulnar nerve may occur secondary to irritation or stretch of the nerve.
If the fracture is treated with a cast alone, x-rays should be checked weekly for the
first 2-3 weeks to ensure proper healing without late fracture line widening.
PROXIMAL ULNA:
CORONOID FRACTURES
The coronoid process remains cartilagenous until the age of 6 years. Most frac-
tures of the coronoid occur in association with elbow dislocation or are associ-
ated with other fractures about the elbow.
Classification—Coronoid Fractures
Regan and Morrey classified coronoid process fractures based on the size of the
fragment (Table 9-4).
Treatment—Coronoid Fractures
Treatment of coronoid fractures is based on the degree of displacement and the
instability of the elbow. In more severe cases, a CT scan will likely be needed to
accurately study the injury. Type I and II fractures without associated injuries
can be treated with casting for 3 weeks followed by early motion. Casting
should be done with the forearm supinated and the elbow flexed to 90°.
Type III fractures typically cause instability of the elbow and require fixation
for stabilization. In children, suture fixation through drill holes is typically ade-
quate fixation if the fragment is anatomically reduced (Fig. 9-23). Again, a
short time in a cast should be followed with early motion.
Type II Type III
A single or comminuted fragment A single or comminuted fragment
involving ≤50% of the coronoid process involving >50% of the coronoid process
Pitfalls—Coronoid Fractures 131
Monteggia Fracture/Dislocation
Nonunion of type III fractures can lead to chronic elbow instability and recur-
rent episodes of dislocation. This is rare in children.

MONTEGGIA FRACTURE/DISLOCATION At Injury 1 Year Later

Radial head dislocation is almost universally accompanied by an ulna fracture

or bow in children (Table 9-5). Giovanni Monteggia gave his name to the in-
jury pattern after missing the diagnosis in a young girl in 1814. Lincoln and
Mubarak reviewed so-called isolated anterior radial head dislocations and found
that each case included a subtle greenstick fracture or plastic deformation of the
ulna, suggesting that the term isolated radial head dislocation is a misnomer in
children. Most are actually subtle variations of a Monteggia fracture. Straight-
ening the ulna is important to stability of the radioulnar joint because even a Figure 9-24. Initially this x-ray read as
normal following trauma. One year later
slight ulnar bow can push the radial head out over time (if not immediately) the radial head was found to be dislocated
(Fig. 9-24). and the slight residual bow of the ulna was
Confusion may arise when a child with a preexisting congenital or patho- noted.
logic dislocation falls on the elbow with the ensuing radiographs read as an
acute injury. In puzzling cases, examine and radiograph both elbows. The diag-
nosis of long-standing dislocation can be made (a) if the condition is bilateral or
(b) if unilateral, when the affected radius is longer, the radial head misshapen,
the capitellum hypoplastic, the distal humerus grooved, and/or ossification
more advanced than on the opposite side (Fig. 9-25).

Treatment—Monteggia Fracture/Dislocation
The three critical elements required to treat radial head dislocations include:
1. Straightening the ulna
2. Reducing the radial head
3. Minimizing forces that will redislocate the radial head
Even a slight ulnar bow can keep the radial head dislocated, and therefore the
ulna needs to be corrected to its anatomic position. Greenstick ulna fractures or Figure 9-25. Congenital dislocations of
ulnae with plastic deformation can often be straightened in a closed fashion and the radial head have a different appearance
than acute dislocation. This is a severe ex-
maintained with a cast alone; however, this reduction may require general anes- ample; rarely will it be so obvious.
thesia as it takes a significant amount of force to reshape a bent ulna. We have
often used the readily available small oxygen tank (ever-present in ERs and

Table 9-5 Classification—Monteggia Fracture Dislocations

Type I Type II Type III Type IV

ANTERIOR POSTERIOR LATERAL ANTERIOR

Ulna-metaphysis Ulna-metaphysis Ulna-metaphysis Radial and

or diaphysis or diaphysis ulnar-diaphysis
132
Elbow—Proximal Radius and Ulna
At Injury
After Closed Reduction
Figure 9-26. This less subtle Monteggia
fracture was treated with closed reduc-
tion and casting. The patient went on to
have complete healing and normal motion.
At Injury After Closed Reduction
A B C D
Figure 9-27. A,B) Type III Monteggia fracture/dislocation. C,D) This lateral dislocation was
reduced and casted in relative extension.
ORs) as a fulcrum to bend the arm back to its normal position. Perfect align-
ment may require completing a greenstick ulna fracture.
Experienced surgeons can often reduce and maintain Monteggia fractures
using closed methods (Fig. 9-26). Maintaining anatomic alignment of the ulnar
fracture sometimes requires open reduction and fixation with a plate and screws
or an intramedullary pin. An ulna fracture extending through the olecranon,
disrupting the joint surface, usually requires open reduction to restore the joint
surface plus either K-wires and a tension band or a contoured plate and screws.
The radial head is usually easily reduced once the ulna is straight. For type I
and type III anterior dislocations, your thumb can be positioned directly over
the radial head to guide it into place as the elbow is supinated and flexed. Lat-
eral and posterior dislocations tend to require a cast in extension to maintain
the reduction (Figs. 9-27, 9-28). Neviaser reported a child whose radial head
buttonholed through the capsule and required open reduction. However, the
majority of radial head dislocations associated with the Monteggia pattern can
be treated with closed methods (although the ulna fracture may have to be
opened and fixed—Fig. 9-29).
The Kocher posterolateral approach is recommended for the rare occasions
in which open reduction of the radioulnar joint is needed. The forearm should
be kept in pronation during the exposure to prevent injury to the posterior
interosseous nerve. The annular ligament may need to be repaired or recon-
structed to maintain the reduction.
Giovanni Monteggia
1762–1815
Monteggia was born at Lake Maggiore, Italy. He studied in
Milan where he became professor of surgery. He is partic-
ularly remembered for his description of a fracture dislo-
cation of the forearm that he described in the same year
that Colles described his fracture.
At Injury 133
Monteggia Fracture/Dislocation

Figure 9-28. This Type II Monteggia frac-

ture (posterior) was reduced and casted
in extension to maintain reduction.

Reduced—Cast In Extension

Following reduction of anterior dislocations, the forearm should be immobi- “Failing to recognize a subtle
lized in 90°-100° of flexion with near full supination to keep the radial head re-
radial head dislocation can
duced while the ulna fracture heals. Flexion minimizes the pull of the biceps,
which is the major deforming force in anterior dislocations. Supination gives lead to catastrophe”
maximum stability to the joint, reducing the force of the supinator muscle,
which may deform the proximal ulna. Check films are taken in 7-10 days to
confirm maintained alignment.

At Injury After Reduction

Figure 9-29. Anatomic alignment of the ulna must be maintained to keep the radial head reduced—sometimes this requires pin fixation.
134 Pitfalls—Monteggia Fractures
Elbow—Proximal Radius and Ulna
Failing to recognize a subtle radial head dislocation can lead to catastrophe. Late
reconstruction is often difficult with less than perfect results. For persistent sub-
luxation/dislocation or delayed diagnosis cases, several operative methods have
been proposed to reduce the radial head. Bell-Tawse proposed annular ligament
reconstruction with a strip of triceps tendon. Other surgeons have used material
such as lacertus fibrosis, forearm fascia, palmaris longis, or fascia lata to recon-
struct the annular ligament. An ulnar osteotomy with or without annular liga-
ment reconstruction may be necessary to keep the radial head reduced. Motion
following surgery may be limited by stiffness. Every effort should be made to
make the correct diagnosis early. Always look at the radial-capitellar joint first
when assessing an arm or elbow x-ray!

SUMMARY
Proximal forearm fractures can be very complex in terms of both diagnosis and
treatment. Subtle fractures are easily missed and can lead to long-term disabil-
ity. Even in the best surgeons hands, many proximal forearm fractures lead to
stiffness and pain.

Suggested Readings
Bado, JL. The Monteggia Lesion. Clinical
Orthopedics 50:71-86, 1967.
Beaty JH. Rockwood and Wilkins fractures
in children. 5th ed. Philadelphia, Lippin-
cott, Williams, and Wilkins 2001.
Bell Tawse AJ. The treatment of malunited
anterior Monteggia fractures in children.
J Bone Joint Surg Br. 1965 Nov;
47(4):718-23.
Gicquel P, Maximin MC, Boutemy P, Karger
C, Kempf JF, Clavert JM. Biomechanical
analysis of olecranon fracture fixation in
children. J Pediatr Orthop. 2002 Jan-
Feb;22(1):17-21.
Gillingham BL, Rang M. Advances in chil-
dren’s elbow fractures. J Pediatr Orthop
1995 15(4)419-28.
Gonzalez-Herranz P, Alvarez-Romera A, Bur-
gos J, Rapariz JM, Hevia E. Displaced
radial neck fractures in children treated by
closed intramedullary pinning (Metaizeau
technique). J Pediatr Orthop. 1997 May-
Jun;17(3):325-31.
Kay RM, Skaggs DL. The pediatric Mon-
teggia fracture. Am J Orthop. 1998
Sep;27(9):606-9.
Kosuwon, W. et al. Ultrasonography of
pulled elbow. JBJS 75B:421-22, 1993.
Letts M, Locht R, Wiens J. Monteggia frac-
ture-dislocations in children. J Bone Joint
Surg Br. 1985 Nov;67(5):724-7.
Lincoln TL, Mubarak SJ. “Isolated” trau-
matic radial head dislocation. Journal of
Pediatric Orthopedics 14:454-457, 1994.
Neher CG, Torch MA. New reduction tech-
nique for severely displaced pediatric ra-
dial neck fractures. J Pediatr Orthop.
2003 Sep-Oct;23(5):626-8.
Regan W., Morrey, BF. Classification and
treatment of coronoid process fractures.
Orthopedics 15:845-848, 1992.
Salter, RB, Zaltz, C: Anatomic investigations
of the Mechanism of Injury and Patho-
logic Anatomy of Pulled Elbow in Young
Children. Clin Orthop, 77:134-143,
1971.
Skaggs DL. Elbow Fractures in Children: Di-
agnosis and Management. J Am Acad
Orthop Surg. 1997 Nov;5(6):303-312.
Smith GR, Hotchkiss RN. Radial head and
neck fractures: Anatomic guidelines for
proper placement of internal fixation. J
Shoulder Elbow Surg. 1996 Mar-Apr;5(2
pt 1):113-7.
Triantafyllou, SJ et al, Irreducible pulled
elbow in a child. A case report. Clin Or-
thop 284:153-155, 1992.
Vocke AK, Von Laer L. Displaced fractures
of the radial neck in children: long-term
results and prognosis of conservative
treatment. J Pediatr Orthop B. 1998
Jul;7(3):217-22.
Weisman DS, Rang M, Cole WG. Tardy dis-
placement of traumatic radial head dislo-
cation in childhood. J Pediatr Orthop.
1999 Jul-Aug;19(4):523-6.
 Radius and Ulna
10
Mercer Rang m Philip Stearns m Henry Chambers

:
• Anatomy and Pathology 136
• Assessing the Patient 137
• Radiographic Issues 137
• Distal Fractures—Physeal 139
• Distal Fractures—Above Physis 140
• Midshaft Fractures 143
• Flexible Intramedullary Nail Fixation 147
• Remodeling 148
• Refracture 149
• Malunions 149

INTRODUCTION “Convictions are

The influx of extreme sports and activities has increased a child’s risk for fracture.
Even children at a young age participate in these more risky activities. When a
more dangerous
child falls off a bike, scooter, or skateboard, the upper extremity bears most of enemies of truth
the force, particularly the forearm and wrist because the arms are often used to
brace one’s fall: This is a variation of the parachute reflex (Fig. 10-1). The para- than lies”
chute reflex protects the vital organs often at the expense of the forearm.
Fractures of the radius and ulna, especially about the wrist, are the most —NIETZSCHE
common children’s fractures. In many ways, these fractures are different from
those of adults:
! Shattering injuries of the articular surfaces of each end of the radius are less
common.
! The bones may bend or plastically deform without a complete fracture.
135
136
Radius and Ulna
Figure 10-1. Children of every age enjoy
a variety of sports. This junior bull rider
suffered bilateral distal radius fractures
from this fall. (Photo courtesy of R. Knud-
son.)
Figure 10-2. Malrotation limits move-
ment. Ninety degrees of pronation de-
formity, as shown here, limits pronation
to the midposition, because the proximal
radioulnar joint has reached the limit.
! Nonunion is rare.
! Fractures of the shafts of both bones of the forearm can usually be managed
closed, therefore requiring reduction and casting skills that adult forearm
fractures do not.
! Forearm fractures in children have remodeling potential, which does not
exist in adult forearm fractures.
ANATOMY AND PATHOLOGY
The forearm bones are subcutaneous in the lower half of the forearm. The qual-
ity of reduction can be appreciated, not only by the surgeon but also by the pa-
tient when the cast comes off.
Forearm rotation has a range of 180°, perhaps the greatest range of rotation
of any joint in the body. Although a decrease of rotation by 50% may go unno-
ticed for most activities, fractures should be reduced well so that patients will
regain full rotation.
Loss of rotation is a common problem after forearm fractures. Knight and
Purvis found residual rotational deformity of between 20° and 60° in 60% of
cases. Evans found malrotation deformity of more than 30° in 56% of cases
with the distal fragment pronated so that supination was lost.
Fractures have been produced in cadavers and plated with various types of
malunion to determine the effects of each.
! Ten degrees of malrotation limits rotation by 10° (Fig. 10-2).
! Ten degrees of angulation limits rotation by 20° (Fig. 10-3).
! Bayonet apposition does not limit rotation.
! Pure narrowing of the interosseous distance is important in proximal frac-
tures. (Narrowing impedes rotation by causing the bicipital tuberosity to im-
pinge on the ulna.)
! Malalignment of fractures of the ulnar metaphysis increases the tension on
the articular disc so that the head of the ulna is not free to rotate (Fig. 10-4).
Figure 10-3. Angulation malunion limits ro-
tation, because the interosseous membrane Figure 10-4. Angulation of the distal ulna pre-
cannot widen and narrow. vents rotation of the ulna.
ASSESSING THE PATIENT 137
Radiographic Issues
Some injuries to the forearm are more obvious than others. First, observe the ex-
tremity to see how the child holds it and if there is deformity. With severe defor-
mity, the child will be difficult to examine due to pain, fear, and other concerns.
The joints above and below the suspected site of injury are examined to rule out
other injuries. The Monteggia injury is the classic (Chapter 9); however, supra-
condylar fractures are commonly seen along with a distal radius fracture.
Assessment is important but may be difficult in a very unhappy child. Pulses,
nerve function, and forearm compartment status are noted. Document only
what you can confirm (Chapter 8). Look at the forearm in its position of dis-
placement. You should be able to tell from the shape of the arm how the distal
fragment lies in relation to the proximal part.
It sometimes helps if first the part of the arm below the fracture is blocked off
from vision with a hand and then the part above. If the upper part of the arm lies
in supination, and the distal part looks as if it is pronated, a simple supination
force on the hand will reduce the fracture. The first person that sees the child has
a great advantage, because he/she is the only one who can see the limb as it lies
(Fig. 10-5). Prior vigorous splinting may make this analysis problematic.
The skin exam is critical. Often, there is a small puncture wound where a
bone end stuck through the skin and then retracted back. The spike of bone
may have pulled debris and bacteria back inside with it. If you can express
hematoma out through a puncture hole, it should be considered an open frac-
ture and treated appropriately.
Figure 10-5. Typical deformity in a fore-
Despite the presence of closed fascial spaces in the forearm, the risk of is- arm fracture. A fracture with this deformity
chemic contracture is low if a well-padded splint or split cast is used. Nerve in- (apex dorsal angulation) often is most eas-
juries are also rare but can occur from stretch or laceration. ily reduced by supination.

RADIOGRAPHIC ISSUES
Standard AP and lateral views of the forearm are the usual films performed when a
child has a forearm injury. A separate elbow film may be needed to evaluate the re-
lationship between the radial head and the capitellum (Monteggia injury). Beware
the forearm film that does not clearly show the radial head–capitellar relationship
or because the x-ray technician has placed the name plate over this vital area.

Radius
The radius is a curved bone that is pear-shaped in cross section. Malrotation of
the radius is recognized by a break in the smooth curve of the bone and by a
sudden change in the width of the cortex (Fig. 10-6).

Angulation
Angulation that produces a volar apex or prominence is conventionally described
as volar angulation or bowing. Some describe the distal fragment as being dorsally
displaced or tilted. If the distal fragment is tipped in the palmar direction, a dorsal
angulation is created. This is worth stating clearly because telephone conversa-
tions about fractures are frequently plagued by semantic ambiguities (Chapter 3).

Rotation Figure 10-6. A change in the diameter of

the radius, the width of the cortex, and the
X-rays are two-dimensional so it is difficult to recognize and understand rota- smooth curve of the radius indicate malro-
tional deformity. A supination or pronation force causes most fractures. For tation.
138
Radius and Ulna
Figure 10-7. Angulation is usually associ-
ated with rotation. Use a strip of paper to
prove this yourself.
“Prior to the discovery of x-
ray films, surgeons had to
guess the position of the
proximal fragment, and
some surgeons still do”
example, when a child extends the hand to break a fall, the pronated thenar em-
inence hits the ground first and an immediate supination force is applied. The
radiographic appearance of this fracture seems to be apex volar angulation, but
the displacement is usually rotational. Test this for yourself with a strip of paper,
as shown in Figure 10-7. If the surgeon considers only the angulation and cor-
rects it, the rotational deformity will remain uncorrected. An apex volar fracture
is often more accurately reduced by applying a pronation force to the hand,
whereas an apex dorsal fracture is usually better reduced with a supination force
to the hand.
Prior to the discovery of x-ray films, surgeons had to guess the position of the
proximal fragment, and some surgeons still do, using the traditional argument
that muscle pull determines the position of the proximal fragments. Classic
dogma included that “in the case of fractures above the insertion of pronator
teres, the proximal fragment is invariably pulled into supination by supinator
muscles. The fracture should be immobilized in supination. Fractures below the
insertion of pronator teres are invariably pulled into pronation by this muscle
and should therefore be immobilized in this position.” Although this theory is
often repeated and has certain logic, it is often not true.
Position of Bicipital Tuberosity
The bicipital tuberosity is a good landmark for understanding rotation. It nor-
mally lies medially when the arm is fully supinated, posteriorly in mid-position,
and laterally in full pronation (Fig. 10-8). This method is better applied in
older children who have a more prominent tuberosity.
In complete fractures, the rotational position of the proximal fragment can
be identified by this method, and reduction becomes more scientific. The distal
fragment is lined up in the same degree of rotation as the proximal fragment,
which usually maintains its normal position.
Figure 10-8. (Left) the bicipital tuberosity as a guide to the rotation of the proximal radius.
(Right) If you cannot remember where the bicipital tuberosity should be, put an ink mark on
your palm at the site indicated.The prominance of the tuberosity always points in this direction.
Application 139
Distal Fractures—Physeal
The previous theories must be learned and applied when reducing forearm frac-
tures. Although useful in achieving reduction, casting in distorted positions of
rotation makes x-ray analysis difficult. Except for extreme cases, we apply a long
arm (above elbow) cast in neutral rotation (after using rotational theory to “Although useful in
achieve reduction). Follow-up x-rays are much easier to analyze (clear AP and achieving reduction, casting
lateral views). A compromise seems best. Rotational and angular concepts are
used to achieve reduction; then when possible, the cast is applied in neutral or in distorted positions of
near neutral rotation to allow production of more easily interpretable x-rays. rotation makes x-ray
analysis difficult”
DISTAL FRACTURES—PHYSEAL
Salter-Harris Type I Injuries
Type I injuries are seen in younger children, are seldom much displaced, and are
diagnosed on clinical suspicion more than by radiographic findings (Fig. 10-9).
Swelling and tenderness at the growth plate, despite normal radiographs, are A
our grounds for making this diagnosis. The radiograph may demonstrate a
slight widening of the physis. Protection for 3 weeks in a cast or removable
splint provides adequate treatment. You may think this is over-treatment, but
the entity is common, real, and painful. A cast relieves the symptoms and stops
the parents worrying and telephoning. On follow-up exam callus formation B
may be seen on the radiograph confirming the diagnosis. In general, only cases
with more severe trauma would have follow-up to rule out occult physeal in-
jury.

Salter-Harris Type II Injuries

Type II injuries are the most common, usually associated with posterior dis- C
placement (volar angulation) and are frequently accompanied by a chip off the
Figure 10-9. Typical SH I fracture. A) Dia-
ulnar styloid (Fig. 10-10). gram illustrating bleeding and swelling but
This angulation pattern is often referred to as a Colles fracture (although without displacement. B) X-ray at injury
Colles described it in adults). For typical volarly angulated Type II fractures, (normal). C) Treatment—either cast or
wrist flexion alone may not maintain the reduction, because the wrist joint splint (if patient is cooperative) can be used.

Figure 10-10. The typical SH II fracture of

the distal radius (with volar angulation) can be Figure 10-11. Hyndman et al. studied the ratio of the cast width for maintaining fracture
reduced with a hematoma block or conscious reduction. The lateral diameter (A) must be significantly less than the AP diameter (B) to
sedation. maximize molding and stability.
140
Radius and Ulna
Figure 10-12. Smith variant or fracture
with anterior displacement of the distal
fragment are common following falls from
scooters.This is also a Salter-Harris II injury.
Figure 10-13. Following a severe Type II
injury of the right distal radius, this patient
had a physeal closure and a resultant wrist
deformity. Earlier recognition could have
allowed better treatment.
Figure 10-14. Classic buckle fracture of
distal radius, best noted on lateral view.
flexes easily to 80° before the capsule tightens enough to exert any influence on
the distal fragment. Thus in addition to moderate wrist flexion, three-point
molding must be optimized (Chapter 5).
We often use a long arm (above elbow) cast, although Hyndman and then
Galpin (POSNA—2004) have demonstrated that a short arm (below elbow)
cast can maintain many reductions if the AP and lateral cast diameter ratios are
correct (excellent molding required—Fig. 10-11).
Distal physeal fractures can also be seen with anterior displacement (dorsal
angulation—Smith variant) due to a fall from a bike, scooter, etc. These Smith-
variant fractures are easily reduced by direct pressure (with appropriate anesthe-
sia). The reduction maneuver and molding are reversed (from Colles pattern)
when the cast is applied (Fig. 10-12).
In 4-6 weeks, the fracture will be united and the cast can be removed. If a re-
duction was performed, the child should return to clinic in 1 week for an x-ray
check to ensure maintenance of reduction. Severe loss of reduction, up to 10
days after the original injury, is usually re-reduced under general anesthesia. If
more than 10-14 days past injury, this re-reduction may damage the physis,
thus the fracture is left in its malreduced position with hope for remodeling. In
rare cases, a late osteotomy will be required.
It is important to discuss the risks of physeal closure with the family. We fol-
low these children at 6 months and even 1 year after the fracture has healed to
assess for premature closure. X-rays of both wrists are taken at follow-up visits
and, if there is suspicion of early closure, a CT or MRI can help to further eval-
uate possible closure.
Salter-Harris Type III and IV Injuries
Injuries that involve the joint surface are less common in children and can be dif-
ficult to see on the radiograph. For these injuries the step offs, depressions, or gaps
at the joint surface as well as physeal congruity are best evaluated with a CT scan.
If significant displacement is seen (!2 mm in any direction), reduction is re-
quired. This can be performed arthroscopically or more typically with a dorsal or
volar incision, depending on where the joint damage is located. Plan your incision
to get maximum exposure of the joint injury. When possible, we try to minimize
internal fixation and use percutaneous pins that are removed after 3-4 weeks,
prior to starting motion. If more permanent fixation is required to maintain the
reduction, all fixation must be countersunk or very low profile; the tendons and
nerves will either be gliding over your metal or catching and tearing on your screw
heads and plate edges with attempts at wrist motion. There are very low profile
and contoured periarticular plates that can be used as a buttress if needed.
Growth
The distal end of the radius is a classic site for growth disturbance owing to
bridging of the physes. Thus all physeal fractures must be followed closely. With
radial physeal closure and ulnar overgrowth, a wrist deformity may begin to ap-
pear (Fig. 10-13). These children should be radiographed every 3-6 months for
signs of a bony bridge so that prompt resection can be carried out.
DISTAL FRACTURES—ABOVE PHYSIS
Buckle or torus fractures are common and usually thought by the family to be a
sprain. When the pain persists for several days and an x-ray is ordered, the diagno-
sis is usually accompanied by guilty feelings on the part of the parent for not
bringing the child in right away. The radiograph demonstrates a “buckle” or wrin- 141
kle in the cortex of the radius (Fig. 10-14). Buckle fractures can be treated either Distal Fractures—Above Physis
with a below-elbow cast or Velcro splint, depending on the child’s activity level.
Minimally angulated fractures require good casting, often a hematoma block
or no anesthesia. Fractures that are apex volar in angulation require a three-
At Injury After Reduction
point flexion type mold as shown in Figure 10-15. These should be followed in
7-10 days to ensure alignment.
Fractures with apex dorsal angulation require an extension type mold. These
also should be followed within 7-10 days (Fig. 10-16).
Also, be wary of nondisplaced fractures that are complete through the volar
cortex. These fractures may tip into apex volar angulation; therefore a cast
should be applied with a flexion type mold. A follow-up x-ray should also be
obtained in 7-10 days. We have seen these fractures angulate in the cast.

Complete Fracture—Both Bones Figure 10-15. Fractures with volar angu-

Complete fractures of the radius and ulna can be very challenging to manage lation (Colles pattern) can be reduced and
maintained with a three-point mold.
(Fig. 10-17). Reduction may be difficult and unstable, particularly .in children
less than 2 years, in older children, in proximal fractures, and in those that are
comminuted or oblique. If both bones are overlapping, reduce them by increas- At Injury After Reduction
ing the deformity as described on the following page. Charnley’s analogy to re-
engaging a gear is important in understanding why the deformity must be made
worse before it can be reduced. Simple distal pull or simple angular forces will
not do.
There are several general rules to guide you:
1. Good reductions last better than poor reductions, particularly in a well-
molded cast.
2. In young children ("10) bayonet apposition is adequate if rotation is cor-
rect, if the interosseous space is preserved, and if there is no angulation.
3. Immobilize the fracture in the position in which the alignment is correct and Figure 10-16. For a fracture with dorsal
angulation (Smith pattern), an extension
the reduction feels stable. Immobilization with the elbow in extension may
mold maintains the reduction. (This patient
be the best position for fractures in the proximal one third of the forearm. was very obese thus the cast diameter on
4. Minor reduction improvements can be made at 1-2 weeks when the fracture the lateral view appears to be too great
is sticky (wedging—Fig. 10-18—or change cast and re-manipulate). but in fact could not be improved due to
5. Be prepared to carry out open reduction and internal fixation, particularly in patient size.)
children older than the age of 10 rather than accept a poor reduction.
6. Always warn the parents before you reduce the fracture that re-manipulation Loss of Reduction After Wedging
is often necessary later and that there will be a bump when the cast comes off.

Initial Deformity
After Reduction

Figure 10-18. Loss of reduction in a both

bone forearm fracture can be corrected
with a wedge or recasting. This case was
Figure 10-17. Distal both bone forearm fractures can be reduced by using the method of corrected by wedging, which must be done
Charnley, described on the next page. very carefully to avoid skin necrosis.
 Closed Treatment of Forearm Fractures

John Charnley
1911–1982
John Charnley, one of the most remarkable surgical innovators of the 20th century, is best
known for his work. in developing a total hip replacement for the treatment of degenerative
arthritis in adults.
Many young orthopedists do not realize the importance of Charnley’s work in fracture treat-
ment. After serving in World War II, Charnley returned to the Manchester Royal Infirmary
where, working with the famed Sir Harry Platt, he developed an extensive experience in the
closed treatment of fractures, leading to his classic text The Closed Treatment of Common Fractures
(See Suggested Readings).

To reduce a fracture the fragments must be disengaged by recreating

the injury.This can then be re-engaged in proper alignment to assist
with reduction.

(Source: Charnley J. The closed treatment of common fractures. Edinburgh: Livingstone, 1980. [Figures reproduced with permission])

142
Solitary Distal Radial Fractures 143
Midshaft
The ulnar styloid is usually avulsed. It may be more difficult to reduce a fracture
of only one bone as the intact bone will not allow the typical reduction maneu-
.
vers. Armed with strong thumbs and awareness of the periosteal hinge, you can
usually reduce these fractures closed. If the fragments are still in cortex-
to-cortex apposition, repeat the maneuver with more thumb pressure. Be care-
ful not to dislocate your own thumb in the process, as a surgeon in our group
did. An OR reduction with K-wire fixation is sometimes required.

Galeazzi’s Fracture
The classic Galeazzi fracture (Table 10-1) is a fracture of the radius (usually at
the junction of the middle and distal thirds) with dislocation of the distal ra-
dioulnar joint; it is less common than Monteggia’s injury. These fracture-dislo-
cations are often missed because one focuses in on the distal radial fracture and
ignores the subluxation or dislocation of the distal radioulnar joint. When look-
ing too hard for these injuries, it is easy to become confused, as a slightly
oblique x-ray of a normal wrist will make the ulna look subluxed. A trick is to
look at the the ulnar styloid, it should be pointing at the triquetrum on all radi- Riccardo Galeazzi
ographic views including obliques. 1866–1952
Galeazzi directed the orthopedic clinic
in Milan for 35 years. He was a con-
MIDSHAFT temporary of Monteggia. Galeazzi de-
scribed a fracture of the distal radius
Midshaft Greenstick Fractures with subluxation of the distal radio-
Minimally displaced fractures are very common. The deformity may be cor- ulnar joint.
Italian eponynms remain among the
rected with corrective pressure while the cast is setting. No reduction effort is most popular and most frequently
made as the cast is applied. Then, as it is setting, a smooth corrective three- quoted in contemporary orthopedic
point mold is applied. Without a good mold, the bone may slowly bend as it discussion.Why? First, Italy has been
heals (Fig. 10-19). (and remains) a center for orthopedic
Angulated greenstick fractures of the midshaft require slight overcorrection ideas. In addition, Italian names have a
to take the spring out of the fracture. You will often hear a crack as the bony pleasant way of rolling off the tongue,
making those who quote them seem a
hinge yields. If this is not done, the deformity may reappear in the succeeding bit wiser.
weeks. On the other hand, a too vigorous maneuver (big doctor, small patient)

Table 10-1 Classification—Galeazzi Fractures

Type I (Most Common) Type II Initial Fracture 4 Weeks Later
Dorsal Subluxation of the Ulna Volar Subluxation of the Ulna

Figure 10-19. This both bone forearm

fracture originally appeared to have ac-
ceptable alignment, but the radius slowly
Supination required for reduction Pronation required for reduction bowed while in the cast, resulting in malu-
nion with loss of motion.
144
Radius and Ulna
Normal
Ulnar Bow
Figure 10-20. Plastic deformation is
much harder to correct and often requires
fracturing the bone to straighten it.
Figure 10-21. Be very careful not to
bend the elbow while applying the cast—
the fiberglass will dig in and produce a sore
(note arrow—cast material kinked at
elbow crease, resulted in skin ulceration in
the cubital fossa).
Figure 10-22. The ability to provide a
careful three point mold with the cast rela-
tively narrow in its dorsal to volar dimen-
sion is critical to maintenance of forearm
fracture reduction.
may create more severe displacement. The periosteal tube is intact and will help
maintain reduction. Supination injuries are pronated and then given a push to
get rid of the anterior angulation, at which time a crack is often heard. The cast
should be well molded to prevent further angulation.
Plastic Deformation
Some fractures do not appear to break any cortex yet the arm has a terrible bend
to it (Fig. 10-20). The radiograph shows a bent appearance of either or both of
the radius and ulna. These are difficult injuries to treat and should be taken to
the OR to obtain reduction under general anesthesia. These fractures do not re-
model and the child is left with an angulated and rotated forearm. A large
amount of force is necessary to reduce these fractures, usually over a rigid object
such as an oxygen canister.
Maintaining Reduction
Examine the radiograph to determine the position of the proximal fragment
(use the bicipital tuberosity as a guide). Try to line the distal fragment up with
the proximal fragment. It is always difficult to hold the limb while the cast is
being applied and two people are required, one to maintain the reduction and
the other to apply a well-molded cast—holding the thumb and index finger,
with slight flexion and ulnar deviation, often helps. Be very careful not to bend
the elbow during or after applying the cast—the fiberglass will dig in and pro-
duce a sore (Fig. 10-21).
Mold the cast well. The cast should have a straight ulnar border, it should be
compressed so the side-to-side dimension is wider than the dorsal to volar di-
mension, there should be a good interosseous mold and three-point molding at
the fracture (Fig. 10-22), and the elbow must be at a perfect right angle. Supra-
condylar molding just above the elbow should prevent the cast from telescoping
up and down the arm. It is difficult to manage all of these factors at one time, so
at least while learning, we recommend applying the cast in two stages, a well-
molded short arm cast can be extended to an above elbow cast. Some argue that
a well-molded short arm cast is more effective than the typical poorly applied
long arm cast.
Reduction is confirmed by fluoroscan views with formal x-rays made for the
record and for subsequent comparison. Carefully analyze the final films. Re-
member that the quality of reduction that is accepted is inversely proportional
to the difficulties involved in changing it. If the position is not satisfactory, try
again. In the end, it is better to deal with the issue now rather than in a 50-
patient clinic next week.
Support the weight of the cast with a cuff and collar or a sling, so that the
weight of the cast will not act as a deforming force at the fracture site. Include
the thumb in the cast if the fracture is very unstable or if the cast is applied with
the elbow in extension.
Other Methods
Many authors advocate an alternative method of reduction for midshaft frac-
tures: Traction is used to reduce and hold the limb while the cast is applied.
Counter traction is provided by a padded sling around the arm. An assistant
pulls on the hand while the surgeon manipulates the bone ends.
Alternatively, finger traps attached to an IV pole can hold the fingers (Fig.
10-23). The fracture is reduced again with traction and manipulation. The cast
is then applied, and the sling is pulled out. Some object to this method because 145
the intact periosteum must be stretched to allow the overlapping ends to jump Midshaft
into end-to-end contact. It is like trying to force a door shut when something is
in the way of the hinge.
A combination of the two concepts provides a nice compromise. Finger traps “Traditional plate fixation,
optimize longitudinal traction while deft thumbs apply an angular and rota- commonly advised for
tional correction. Clearly, time and experience will be needed for you to de-
velop your best method. The reduction should be checked radiographically
adults, is not needed for
weekly for 3 weeks to see if there is any loss of reduction. most children”

When is a Closed Reduction Acceptable?

Price tells us that if the child is younger than 9, then 15° of angulation can be
accepted. Those children older than 9 should not have more than 10° of angu-
lation. Malrotation of up to 45° can be accepted in children younger than the
age of 9 years, while only 30° should be accepted for those older than 9 years.
Shortening is not usually a problem. It is important to remember that the more
proximal the fracture is, the less likely it is to remodel with time. Fractures near
the physis will remodel in the plane of motion, but rotational deformities do
not remodel efficiently.
95 :#
otatien
L 9 =L 150
Angle + <
Open Reduction > a = < 10 + < 30

Traditional plate fixation, commonly advised for adults, is not needed for most
children. Semitubular or compression plates require a large exposure in small
arms. They then require removal, which predisposes the child to refracture.
Most centers now use intramedullary (IM) nailing techniques using a flexible
titanium nail system (Metazeau) or IM K-wires or Steinman pins for internal
fixation in children with open, unstable, or otherwise uncastable forearm frac- Figure 10-23. Finger traps can aid in re-
duction of forearm fractures.
tures (Fig. 10-24, Fig. 10-25).
The term “Nancy nail” is commonly used to describe flexible nailing because
the concept was studied and then widely used and publicized by Metazeau in
“The term ‘Nancy nail’ is
Nancy, France. After widespread use in Europe, the method is now widely ac- commonly used to describe
cepted worldwide. flexible nailing because the
It is controversial as to whether it is necessary to fix both the radius and ulna
in a both bone forearm fracture. Stability of the forearm is the key to success. If concept was studied and
fixation of one bone gives adequate stability for casting, you may get away with then widely used and
only fixing one of the fractures.
publicized by Metazeau in
At Injury After Surgery Nancy, France”
At Injury

After Surgery

Figure 10-24. K-wires can be used for intramedulary

fixation in younger children with severely angulated frac- Figure 10-25. In older children, flexible titanium
tures that fail closed reduction. intramedulary nails give better fixation.
146
Radius and Ulna
“Fractures at or distal to the
metadiaphyseal junction can
be treated with percutaneous
fixation because intra-
medullary fixation may
cause an ulnar angulation at
the fracture site”
Technique
—Elastic (Flexible) Nailing of a Forearm Fracture
Under general anesthesia, the fracture is evaluated under fluoroscopic control. If
there is an open fracture, the bone ends are débrided in the standard fashion.
The fractures may be reduced if possible. Sometimes the fracture will need to be
opened to remove entrapped muscle or periosteum through a small incision. Do
not try to manipulate the fractures over and over again as we have had a few cases
of compartment syndrome after multiple attempted closed reductions and IM
fixation. Occasionally, it will be difficult to reduce both of the bones at the same
time and one is faced with the decision of which bone to place the pin in first.
We usually choose the one that was most difficult to reduce (usually the radius).
Fractures at or distal to the metadiaphyseal junction can be treated with per-
cutaneous fixation (Fig. 10-26) because IM fixation may cause a significant
ulnar angulation at the fracture site. These fractures are metaphyseal and heal
quickly, so percutaneous pins can be removed after 3-4 weeks. In more distal
fractures, it may be necessary to place the K-wire across the physis (we haven’t
had a physeal closure yet).
Diaphyseal fractures do not do well with percutaneous K-wire fixation; we
have had complications of loss of reduction after pin removal at 4 weeks and os-
teomyelitis from leaving the pins out of the skin. IM fixation is preferred for
shaft fractures. K-wires can be used for small children, Steinmann pins can be
used, or flexible titanium nails can be used as described by Metazeau.
The starting point for a radius fracture is distal. If possible, one should place
the pin (or rod) proximal to the distal radial physis starting on the radial side.
Some physicians use Lister’s tubercle on the dorsal aspect of the distal radius as
a starting point. A small incision is made carefully looking for and protecting
the superficial branch of the radial nerve. A drill just slightly larger than the pin
or rod should be used. The pin or rod should be prebent to make passage down
the bone easier. The tip is curved to bounce off the far cortex after insertion. A
gentle long C shape improves three-point contact and reduction stability.
After the pin is across the radial fracture, the ulna pin can be placed. It can be
placed through the proximal apophysis or just distal to the apophysis on the lat-
eral aspect of the ulna. We recommend reversing the prebent titanium nails and
passing the straight end in the ulna.
Some authors prefer to place the ulnar pin from distally because it is easier to
view under fluoroscopy. One must put a smaller bend on the tip, as the ulnar di-
aphysis intramedullary space is often fairly narrow. It is important to bury the
Figure 10-26. Fractures at or distal to the metadiaphyseal junc-
tion can be treated with percutaneous fixation if unstable.
TECHNIQUE TIPS: 147
Flexible Intramedullary Nail Fixation Midshaft

of Forearm Fractures

For the radius, make a small incision on the dorsal-

radial aspect of the wrist, just proximal to the phy-
sis. Care must be taken to protect the superficial
branch of the radial nerve.

An oblique hole is made in the dorsal-radial meta-

physis with a drill (only drill one cortex). Gently
widen the hole by spinning the drill and lowering it
so that it is near parallel to the shaft.

A prebent K-wire or flexible titanium nail is passed

to the fracture site. This must be bent so that on
entry, when the far cortex is encountered, the pin
bounces off the cortex and can be directed down
the shaft. We recommend a 20°-30˚ bend at the
tip and an additional gentle bend 1-2 cm from the
tip.

Fluoroscopy or direct visualization (if open frac-

ture) is used during fracture reduction. The bent
tip of the pin can be used to aid the reduction and
the pin is passed into the proximal radius—stop-
ping short of the physis (usually at the level of the
bicipital tuberosity). The pin is cut close to the
bone, leaving enough length to allow for later re-
moval but not so prominent that the skin will be
tented.The skin is closed over the tip.

For the ulna, if the pin is inserted through the tip

of the olecranon, one has a straight shot down the
shaft.The prominent pin with little soft tissue cov-
erage is often bothersome to the patient; lateral
starting point on the olecranon allows the pin to
be buried but requires a slight curve at the tip and
may be trickier to pass.

(Variation of technique described by Lascombes, Prevot, Ligier et al.—see Suggested Readings.)

148
Radius and Ulna
Figure 10-27. John Poland’s classic 1896
text included this illustration of a boy
whose fracture remodeled (pre x-ray era).
pin below the skin, as these fractures often take longer to heal because of an open
fracture, the need for open reduction, and/or the fact that it is diaphyseal. We
still use an above elbow cast for these fractures for 6 weeks. The pins can be re-
moved at 6 months or whenever there is complete healing of the fractures.
REMODELING
Children’s forearm fractures have an amazing capacity to improve their radi-
ographic appearance with the passing of the months (Figs. 10-27, 10-28).
Friberg has shown that fractures at the distal end of the radius will correct at the
rate of about 1° a month or 10° a year as a result of epiphyseal realignment.
=
However, diaphyseal malunion is unforgiving. The bone may round off on radi-
ographs so that the site of the fracture disappears, but the arm looks just as
crooked and lacks just as much rotation as when the cast was removed. This
should be described as “rounding off ” rather than “remodeling.”
A few rules may help:
1. Only crude predictions can be made about remodeling.
2. Perfect function can only be promised when the fracture remains perfectly
aligned.
3. Bayonet alignment or overlapping may be unstable but can be compatible
with acceptable alignment.
4. Realignment of a malunited fracture occurs as a result of epiphyseal growth.
The malunion does not straighten. For every 10° of metaphyseal malunion,
a year’s growth should lie ahead for correction.
5. Diaphyseal malunion that blocks more than 50% of rotation and looks ugly
should be treated by osteoclasis not benign neglect.
↳ surgical destruction of Done (
correction of mahnied
Gandhi noted that angulation at the distal end corrects well if the growth
plate has five or more years of activity. Some degree of angulation can be ac-
cepted in children younger than the age of 10.
In the midforearm, angulation corrects poorly and limits rotation. Every ef-
fort should be made to maintain a reduction free of angulation or rotation.
6 Months Post 1 Year Post
Day of Injury 6 Weeks Post Injury Injury Injury
Figure 10-28. Distal fractures with residual angulation have good potential for remodeling
if the patient has remaining growth.
REFRACTURE 149
Malunions
A small proportion refracture within a few months. These are more difficult to
manipulate and may require general anesthesia to achieve reduction. Late re-
fracture (up to 1 year post injury) may be seen (Fig. 10-29). One can try a pro-
tective splint post-casting, but it is rarely used for more than a few weeks. The
risk for refracture must be explained to the family so that the responsibility for
guarded activity is theirs.
Price has noted that late re-fractures are more common when the initial re-
duction is less adequate with residual angulation. The physically dynamic pa-
tient requires the most perfect reduction

MALUNIONS
Fractures of the forearm and wrist are the most common injuries in childhood.
Although the majority are easily treated, the occasional case will be under-
estimated or the patient will miss follow-up appointments and return with poor
result. One Year After Fracture
So what should you do with the child who presents with malunion a few
weeks after the cast has been removed at Elsewhere General Hospital? Angular
deformity at the distal end in a young child always improves. Rotational de-
formity at the distal end, midshaft deformity, and deformities in teenagers do
not remodel well. It does not help to send these individuals away with reas-
suring words. They must either accept what they have or accept correction.
The parents have already been disappointed once. The choice of correction
lies among:
1. Manual osteoclasis. Don’t try this. The bone will break at a distance from the
malunion and leave you with a dog-legged arm.
2. Drill osteoclasis. This is the method of choice. Make a 5-mm incision
over the malunion. Use a drill guide or a trocar to protect the soft tissues
as you make several holes in the bone with a powered drill. Drill both the
radius and ulna, keeping away from the nerves. Crack the bone and im-
mobilize it in a cast, sometimes with the elbow in extension. Take x-ray After Osteotomy
films frequently.
3. Osteotomy and plating (Fig. 10-30). Trading a scar for a deformity is a basic
tenet of orthopedics. The cosmetic disadvantage has lead us to avoid plating
in primary fracture treatment, but it is the most exact method.

Refracture
Malunion

Final Treatment

Figure 10-30. Malunions with resultant

loss of function are best treated with osteo-
Figure 10-29. Both bone forearm fractures that heal with residual deformity are at high clasis or osteotomy and internal fixation.
risk of refracture.
150 SUMMARY
Radius and Ulna
A knowledgeable pediatric care provider can treat the majority of these injuries
in a closed fashion. Forearm fractures in children require reduction and casting
skills as nowhere else in the body. It is important to study and understand the
mechanics of fractures and their reduction. These fractures also need to be fol-
lowed closely as they may drift in the cast and cause significant deformity and
loss of function.

Suggested Readings
Blackburn N, Ziv I, Rang M: Correction of
the malunited forearm fracture. Clin Or-
thop 1984;188:54-57.
Chess DG, Hyndman JC, Leahey JL, Brown
DCS, Sinclair AM: Short arm plaster
cast for distal pediatric forearm fractures.
J Ped Orthop 1994;14:211-213.
Flynn, J.M. Pediatric forearm fractures: de-
cision making, surgical techniques and
complications. AAOS Instructional
Course Lectures, 51:355-360, 2002.
Galpin, RD et al, A Comparison of Short
and Long-Arm Plaster Casts for Displaced
Distal-Third Pediatric Forearm Fractures:
A Prospective Randomized Trial. POSNA
Instructional Course Lectures. 2004.
Jones, K., Weiner, D. The management of
forearm fractures in children: a plea for
conservatism. J Ped Orthop., 19:811-
815, 1999.
Lascombes P, Prevot J, Ligier J, et. al.
Elastic stable intramedullary nailing
in forearm fractures in children: 85
cases. J Pediatr Orthop 10:167-171,
1990.
Lee, S., Nicol, R.O., Stott, N.S. In-
tramedullary fixation for pediatric unsta-
ble forearm fractures. Clin. Orthop.,
402:245-250, 2002.
Price CT, Scott DS, Kurzner ME, Flynn JC.
Malunited forearm fractures in children.
J Ped Orthop 1990;10:705-712.
Shoemaker SD, Comstock CP, Mubarak SJ,
Wenger DR, Chambers HG: In-
tramedullary Kirschner wire fixation of
open or unstable forearm fractures in chil-
dren. J Ped Orthop 19:329-337, 1999.
Trousdale RT, Linscheid RL: Operative Treat-
ment of malunited fractures of the forearm.
J Bone Joint Surg Am 1995;77:894-902.
Verstreken L, Delronge G, Lamoureux J:
Shaft forearm fractures in children: In-
tramedullary nailing with immediate mo-
tion: A preliminary report. J Ped Orthop
1988;8:450-453.
Walsh, H.P.J.; McLaren, C.A.N.; and Owen,
R.: Galeazzi fractures in children. J Bone
and Joint Surg., 69-B:730-733, 1987.
 11Hand
C. Douglas Wallace m Dennis Wenger

• Phalangeal Fractures 153

• Metacarpal Fractures 157
• Thumb Injuries 159
• Carpal Injuries 160
• Crush Injuries 162
• Nerve and Tendon Injuries 162

INTRODUCTION
Hand injuries in the pediatric population frequently lead to an emergency room
“Most people
visit for evaluation and management. The mechanisms vary from the proverbial
fall on an outstretched hand to torsional injuries of the digits in sports, crush in-
would succeed in
juries from children dropping heavy objects on their own or others’ hands, plus a small things, if they
myriad of other causes from the vigorous lifestyle of a normal, active child.
Due to the intricate nature of hand function, attention to detail is required were not troubled
in managing these injuries. Children are well known for their ability to remodel
fractures that have healed with some angulation. Pediatric hand fractures are no with great
exception to this; however, certain limitations exist in the remodeling capacity
of a pediatric hand injury. Similar to forearm fractures, hand fractures that ambitions”
occur close to a physis have substantially greater ability to remodel than those
that occur distant to the physis.
—HENRY
Angular malalignment directly adjacent to a phalangeal physis may be well
tolerated and remodel in time, whereas malalignment distally in the same pha-
WADSWORTH
lanx may lead to permanent deformity and dysfunction. Malrotation has not LONGFELLOW
been demonstrated to remodel in hand injuries.

151
152
Hand
“Due to the intricate nature
of hand function, attention
to detail is required in
managing these injuries”
Figure 11-1. Angular malalignment is
usually easy to detect with the digits ex-
tended. This patient has a fracture of the
little finger proximal phalanx.
Figure 11-2. This subtle distal pole
scaphoid fracture was apparent only on
the scaphoid (oblique) view of the wrist.
Common Abbreviations Used by Hand Surgeon
MP ! metacarpal-phalangeal
PIP ! proximal interphalangeal (finger)
DIP ! distal interphalangeal (finger)
This short chapter will present only the most common children’s hand frac-
tures. Many specialized texts are available for more complex injuries.
PHYSICAL EVALUATION
Evaluation of a child’s hand injury can be challenging because children in gen-
eral fear strangers, particularly those in white coats. A child with a painful hand
injury can be extraordinarily uncooperative and difficult to evaluate.
Nonetheless, the responsibility falls on the treating physician to evaluate the
child’s hand for important characteristics that can be gleaned from careful ob-
servation of the child’s hand with minimal contact.
One should look closely at the child’s hand for evidence of rotatory or angu-
lar malalignment (Fig. 11-1). This can occasionally be seen with observation
alone. More accurate assessments can be made by combining observation with
gentle manipulation of the hand to study the functional alignment of each joint
within the hand. Specific observation of the rotation of the nail beds with the
digits both extended and flexed aid in determining rotatory problems.
Angular malalignment is usually easy to detect with the digits in an extended
position; however, on occasion the swelling in juxtaarticular fractures can mask
angulation.
When palpating the digits for tenderness, the examiner should consider the
structures that pass beneath and the potential for underlying damage. Vascular
assessments, specifically the digital Allen’s
. test, are more practical for the older,
.
more cooperative child. Certainly, capillary refill and digital color can be readily
evaluated even in a very young, screaming child.
Neurologic function of an acutely injured digit is difficult to assess, particu-
larly in the uncooperative child. Sharp/dull discrimination and two-point dis-
crimination becomes a reasonable measurement of nerve function beginning at
approximately age 5 years.
RADIOGRAPHS
Standard AP and lateral plain films (plus obliques as needed) are generally ade-
quate to assess hand injuries (Fig. 11-2). Oblique views are very helpful to assess
metacarpal fractures. In the presence of tenderness in the anatomic snuffbox, a
more detailed evaluation of the scaphoid is warranted and a scaphoid oblique
should be obtained. In cases of ulnar-sided wrist pain, one can consider an
intra-articular contrast MRI in an attempt to elucidate injury to the triangular
fibrocartilage complex (TFCC) and interosseous ligaments.
INITIAL MANAGEMENT
Following examination and initial imaging studies, definitive versus temporiz-
ing treatment should ensue. When immobilizing interphalangeal joints, exten-
sion is the preferred position unless there are reasons in regards to correcting an
angular rotatory deformity to position the digits otherwise. The metacarpopha-
IP ! interphalangeal (finger)
CMC ! carpal-metacarpal joint
TFCC ! triangular fibrocartilage complex (at distal radioulnar joint)
langeal joints should be immobilized in flexion to put the collateral ligaments 153
on stretch and speed recovery of flexion/extension (Fig. 11-3). If the nature of Phalangeal Fractures
the injury precludes this position, then the injury should be managed primarily
with the attention to soft tissue tensions as a secondary consideration. Despite
poor attention to proper mobilization techniques, children often will regain
motion rapidly with minimal deficits nonetheless.
When immobilizing a child with a suspected scaphoid injury, a thumb spica
component should be added to the immobilization device.

INDIVIDUAL INJURIES
The vast majority of pediatric hand fractures can be treated non-operatively. In-
juries frequently requiring surgical intervention include mallet finger deformi-
ties with loss of articular congruity, phalangeal neck fractures with extension or
malrotation, intra-articular fractures of the interphalangeal joints, and a more
generic set of fractures that occur secondary to a crush injury.

PHALANGEAL FRACTURES
Distal Phalangeal Fractures
DP #
~
Tuft fractures are frequent and the vast majority requires solely symptomatic
treatment with protection and splinting for several weeks to allow early healing
of the soft tissue and osseous damage. The patient may return to activities when
comfortable.

Mallet Finger
Figure 11-3. Properly positioned ulnar
The pediatric mallet finger (named mallet because of its appearance if not gutter splint. When immobilizing the hand,
treated) is important to recognize due to potential long-term disability from ideally the MP joints should be flexed and
missed injuries (Fig. 11-4). The mallet finger generally occurs from a jamming the IP joints extended to avoid contracture
type injury, loading the DIP joint. of the intrinsic muscles. This is less impor-
tant in children as they rarely get stiff fol-
There may or may not be a fracture involved. Classically, in the pediatric lowing injury.
population this involves the Salter-Harris III injury in which the extensor
mechanism is attached to the epiphyseal fragment that displaces dorsally. Al-
though this is the most frequent etiology of the juvenile mallet finger deformity,
these can also be due to a tendinous disruption with a negative radiograph.
Management of the mallet finger involves extension splinting across the DIP
joint. It is important to ensure maintenance of congruity of the distal interpha-
langeal joint on the lateral view. In cases where the distal phalanx migrates
At Injury After Surgery
volarly with loss of the articular congruity on the distal aspect of the middle
phalanx, operative intervention is warranted (Fig. 11-5). The degree of displace-

At Injury In Splint 8 Weeks Later

Figure 11-4. Classic Salter-Harris III

fracture that leads to a mallet finger if
left untreated. This child was treated Figure 11-5. Open physeal fracture with
with the dorsal “suspension” splint nail bed disruption requiring débridement,
method of Lester et al. (see next page). repair, and K-wire fixation.
154 ment of the dorsal fragment in general is not the indication for surgical inter-
Hand vention, rather, the articular congruity is.
It is also important to stress that splinting should be in extension but not hy-
perextension. Generally, a dorsally placed splint that in length proceeds from
the PIP joint to a point distal to the tip of the finger held on with tape produces
adequate immobilization. Minimal extension may be added to the splint. A lat-
eral radiograph centered on the DIP joint should be obtained to evaluate artic-
ular congruity. The splint can be adjusted as necessary to provide the best closed
alignment. With preserved articular congruity, 6 weeks of uninterrupted splint-
ing should be adequate to treat this injury.
At the termination of immobilization at 6 weeks, the splint can be worn
while the child is active for an additional 1 to 2 weeks but taken off for bathing
and sleeping purposes to allow gentle reintroduction of motion to the DIP
joint.
Indications for surgical intervention in a mallet finger include volar subluxa-
tion of the distal phalangeal fragment. With loss of articular congruity, long-
term function of the joint cannot be ensured. Therefore closed versus open re-
duction and pin fixation is warranted in this instance.
In addition to this, a Salter-Harris I versus II fracture of the base of the distal
phalanx with significant angulation will have the appearance of a typical mallet
finger deformity but be associated with a nailbed disruption and open injury. In

Suspension Taping Method for Mallet Finger Treatment

1 2 3

4 5 6

The longitudinal taping “suspension taping” method of dorsal splinting

to treat a mallet finger.

Modified from Lester B et al. (see Suggested Readings). Note that Lester
advised leaving the PIP joint free—in children (hand is smaller) we usu-
ally incorporate the PIP joint as well to be sure the splint doesn’t slide
7—Final
off.
these instances, the fingertip droops with bleeding from the eponychial fold. 155
Radiographs generally reflected an intact epiphysis; however, the metaphyseal Phalangeal Shaft Fractures
component is angulated. Treatment includes recreating the deformity for expo-
sure, irrigation, and débridement of any foreign material from the fracture site;
careful reduction of the nail back into the eponychial fold; and fracture reduc-
tion, often with K-wire fixation.
A congenital deformity that can mimic a mallet deformity and present as
such is called a Kirner deformity. A Kirner deformity of the distal phalanx is
formed in a hooked configuration, which gives the finger the appearance of a
drooping tip (Fig. 11-6). This has been known to be overlooked until the child
has an injury to the digit, the parents’ attention focuses on this, and the child is
brought in for evaluation of the finger injury. A lateral radiograph generally will
establish the diagnosis due to the characteristic curved growth pattern of the
distal phalanx.

PHALANGEAL NECK FRACTURES Figure 11-6. Kirner deformity—This

congenital deformity of the distal phalanx
The pediatric phalangeal neck fracture can be a diagnostic dilemma in a very of the fifth finger can be confused with a
young child. In general, these injuries tend to have the distal fragment pushed fracture.
into an extended position (with apex volar angulation). In the older child, this
is obvious on x-ray because the volar subcondylar fossa has been obliterated by
the extension of the condyles. In the young child with nonossified condyles, it
can be extremely difficult to detect. The only indication may be a swollen inter-
phalangeal joint with some malalignment of the shafts. Even then, it may not “Phalangeal shaft fractures
be apparent on plain radiographs. are common in adolescents
Management of these injuries often entails reduction and pin fixation with who are involved in more
cross K-wires (Fig. 11-7). The key is to restore adequate flexion to the digit. As
the distal condylar fragment extends, the fossa into which the articulating pha- vigorous sporting activities”
lanx should enter disappears. A resultant loss of flexion with abutment of the
base of the next phalanx on the neck of the more proximal phalanx can result in
a permanent loss of flexion. Although children can remodel this deformity over
time, it may be necessary in cases of delayed diagnosis to perform an osteoplasty At Injury
to recreate a phalangeal neck fossa to allow flexion of the interphalangeal joint.
The key is to catch this when the fracture is fresh, reduce the extension with di-
rect pressure and/or flexion, and cross pin the condyles into position.
In addition to extension deformities, translation and angular deformities can
also be seen with phalangeal neck fractures (Fig. 11-7). A phalangeal neck frac-
ture with mild angulation can often be reduced under digital block anesthesia.
With careful taping to the adjacent digit, this can hold the fracture in a cor-
rected position that is reasonably stable, allowing closed treatment. If this
proves inadequate, pin fixation can be added to manage the injury.

PHALANGEAL SHAFT FRACTURES After Surgery

Phalangeal shaft fractures are common in adolescents who are involved in more
vigorous sporting activities. These patients must be evaluated for rotatory and
angular malalignment. Again, special attention paid to alignment of the finger-
nails with fingers extended is helpful in determining rotatory alignment
(Fig.11-8).
In addition to this, careful closing of each individual digit should show a
consistent pattern of the finger aiming toward the scaphoid tubercle volarly.
One can place a dot in the palm at the center of the nail on the uninjured hand Figure 11-7. Angulated and unstable pha-
to show the normal alignment and then flex the fingers of the injured hand in- langeal neck fracture requiring reduction
dividually placing a dot at the center of the nail on the palm to indicate the ro- plus percutaneous K-wire fixation.
Figure 11-8. Assessment of fingernails with digits extended Figure 11-9. Drawing dots on the palm at the point where
suggests malrotation of the ring finger. the flexed fingertips reach the palm helps to detect malrota-
tion. The left hand is normal.The ring finger is malrotated in the
right hand.

tatory alignment of the digits (Fig. 11-9). Rotatory malalignment must be

treated to prevent permanent deformity.

PROXIMAL PHALANGEAL FRACTURES

The fracture at the base of the small finger proximal phalanx that results in ab-
duction of the digit is known as an “extra-octave” fracture (Fig. 11-10). These
are usually Salter-Harris II fractures, which can be managed simply with digital
anesthesia block and gentle reduction consisting of flexion at the metacar-
pophalangeal joint with concomitant adduction of the small finger toward and
under the ring finger. Placing a pencil between the ring and small fingers pro-
vides an efficient fulcrum (Fig. 11-11). Placing the MP joint in flexion tensions
the collateral ligaments, which allows reduction of the shaft to near anatomic
reduction. This can be immobilized in intrinsic plus position with the involved
digit and the adjacent digit carefully protected in a cast.

Figure 11-10. The so-called extra-octave fracture of the fifth finger. Left untreated, the child could have a greater hand span
at the piano.

156
 157
After Reduction Metacarpal Fractures

At Injury

Figure 11-11. Placing a pencil between the ring and fifth finger and then applying a brisk ad-
duction force to the small finger provides efficient reduction of an “extra-octave” fracture.

INTRA-ARTICULAR FRACTURES After

Reduction
Another fracture requiring special attention is the phalangeal intra-condylar
intra-articular fracture. Minimal depression of the phalangeal condyle will result
in obvious angular deformity as well as possible premature joint degeneration
due to incongruity of the joint surfaces. Anatomic reduction of the joint surface
is critical for proper management of these injuries. Even a half millimeter of dis- Figure 11-12. Intra-articular phalangeal
placement can lead to angulation and some degree of loss of ultimate function. condyle fracture. Treatment by closed re-
In fresh injuries, reduction can be accomplished with a digital block, use of lig- duction and percutaneous K-wire fixation.
amentotaxis for reduction of the fracture, and pin fixation utilizing smooth
K-wires (Fig. 11-12). In a cooperative adolescent patient, this can be done with
local anesthesia in the clinic/small procedure room setting, using a portable flu-
oroscopy imaging device. A battery-operated pin driver is an excellent tool for
simple management of these fractures.
If anatomic reduction is not attainable in a closed setting, then open reduc-
tion with as anatomic as possible restoration of the joint surface is indicated.
The K-wire fixation in the vast majority of phalangeal fractures should be left in
place 3 to 4 weeks, followed by a gentle motion program.

METACARPAL FRACTURES
Metacarpal fractures can occur at the head and neck region, shaft, or base, sim-
ilar to phalangeal fractures. The most common metacarpal neck fracture in-
volves the distal end of the small finger metacarpal (Fig. 11-13). This is com-
monly called a boxer’s fracture that in the modern world seems more commonly
due to “boxing” (hitting) a wall rather then hitting a human.
Although significant angulation can be tolerated in this region due to the
mobility at the base of the small finger metacarpal, reduction is often indicated
to improve alignment and minimize the need for remodeling. The general
guidelines for management of adult metacarpal neck fracture, as a rough rule,
can also be applied to children (Table 11-1).
Metacarpal shaft fractures occur more commonly with torsional injuries and
are often seen in contact sports when players collide with an oblique blow that Figure 11-13. Typical fifth metacarpal
is transmitted to the metacarpal shaft. These tend to be spiral fractures. (boxer’s) fracture in an adolescent.
158
Table 11-1 Guide for the Treatment of A Boxer’s Fracture (as measured from an oblique hand x-ray)
Hand
Normal 0–30° angulation 30°–50° angulation "50° angulation

Cast only Inject local— Concerted effort

reduction attempt to reduce

Alignment is key and assessment of alignment should be performed with the

digits both extended and flexed at the metacarpophalangeal joint. In theory,
metacarpophalangeal joint flexion in the intrinsic plus position should main-
tain rotational alignment of the fracture (Fig. 11-14). In those instances, con-
trolling anterior/posterior angulation is all that should be necessary with reduc-
tion and casting.
Open reduction and internal fixation are rarely indicated with the exception
At Injury of poor rotatory control, entrapment of the extensor mechanism of the fracture
spike, and inability to control alignment, particularly in a transverse fracture
(Fig. 11-15).
Several metacarpal base fractures are of note in the hand. The small finger
metacarpal may sustain a fracture dislocation at the carpometacarpal level.

At Injury After Open Reduction

After Closed Reduction

Figure 11-14. This fourth metacarpal

fracture was treated with closed reduction Figure 11-15. Fracture of both the fourth and fifth metacarpals in a
and casting with the MP joints in a position teenage boy. Fracture reduction could not be maintained; therefore open re-
of function. duction plus internal fixation were performed.
158
These may be treated with reduction and immobilization if the reduction is sta- 159
ble. If not, they require closed versus open reduction with pin fixation across Thumb Injuries
the CMC level and potentially between the metacarpals as well to maintain
length.
In some instances, comminution is present at the base of the small finger
metacarpal, which is intra-articular. The degree of comminution may be diffi-
cult to assess without the assistance of a CT scan for both severity assessment as
well as preoperative planning (if necessary).

THUMB INJURIES In Cast After

Attempted 4 Weeks
Several injuries are unique to the thumb metacarpal and/or have enough atten- At Injury Reduction Later
tion paid to them to warrant separate discussion.

Base of Metacarpal
Injuries to the thumb carpometacarpal region occur in children as well as in
adults. Bennett fractures (intra-articular fracture of the CMC) can occur and
tend to be in the adolescent to young adult population. These require treatment
similar to adults to stabilize the CMC level with accurate reduction and pin fix-
ation.
Extra-articular fractures are more common. These tend to occur in younger
children as a Salter-Harris II versus metaphyseal injury. Although some remod-
eling is possible, an accurate reduction is optimal. Often, this can be obtained
with a local anesthesia block and gentle manipulation consisting of traction
with direct pressure volarly over the apex of the deformity with support under
Figure 11-16. Base of metacarpal thumb
the metacarpophalangeal joint (Fig. 11-16). Care must be taken not to hyperex- fracture with moderate angulation, the
tend the metacarpophalangeal joint in the process. joint is not involved. Slight reduction was
A thumb spica cast with careful molding to hold the position of the frag- gained and the final result was satisfactory.
ments is applied. In cases of severe deformity, loss of reduction, or inability to
attain adequate reduction, pin fixation should be performed. Generally, this can
be performed percutaneously.

Gamekeeper’s Thumb
At Injury After Surgery
Metacarpophalangeal joint injuries, relatively common in the teenage popula-
tion, are often associated with contact sports. A bony or soft tissue gamekeeper
lesion can occur in this group. The diagnostic dilemmas in the adult population
are also seen in the young adult/adolescent population. When tenderness is
identified at the metacarpophalangeal joint level of the thumb, radiographs
should be obtained prior to stressing the ligaments because a bony gamekeeper
lesion may be present and further displacement of the fragment should be
avoided. Surgical criteria are similar to those in the adult population. Accurate
reduction of the volar/ulnar portion of the proximal phalanx of the thumb is
important for ligamentous stability (Fig. 11-17).

Dislocations
Metacarpophalangeal joint dislocations are reported in the pediatric popula-
tion. The proximal phalanx usually displaces dorsally on the metacarpal head
Figure 11-17. This teenage lacrosse
and neck region. There are both reducible and irreducible forms.
player presented with thumb MP joint pain
In general, the more easily reducible form has hyperextension at the metacar- after an injury. After diagnosis as a game-
pophalangeal joint with mild proximal migration of the base of the proximal keeper’s thumb (with bony avulsion), surgi-
phalanx of the thumb. Dislocations less amenable to closed management tend cal reduction was performed.
 At Injury
Figure 11-18. Typical thumb MP joint dislocation in a teenager. A translational force (not distraction) allowed closed
reduction).
Figure 11-19. The so-called anatomic
snuffbox is formed by the extensor and ab-
ductor tendons of the thumb.The scaphoid
bone lies just under the center of the tri-
angle. A patient with a scaphoid fracture
will likely be very tender in this area.
Figure 11-20. Delayed union—scaphoid
waste fracture in a 15-year-old boy who
fell at football practice. Note lack of callus
despite 10 weeks of immobilization.
160
After Closed Reduction
to be dislocated dorsally, with the phalanx and metacarpal shaft colinear. When
reducing a metacarpophalangeal joint dislocation after obtaining radiographs to
rule out fracture component, one must be careful to not distract the metacar-
pophalangeal joint. Rather than distraction, the reduction maneuver entails
gentle translation of the base of the proximal phalanx along the dorsum of the
metacarpal head and neck region to bring it back onto the distal aspect of the
metacarpal (Fig. 11-18). By preventing distraction, one may avoid entrapping
the volar plate between the metacarpal and proximal phalanx. Immobilization
should be with the metacarpophalangeal joint in a gently flexed position for ap-
proximately 4 weeks. Occupational therapy is often necessary to regain motion
in this joint.
CARPAL INJURIES
Scaphoid (carpal navicular) fractures are often seen in vigorous, athletic, adoles-
cent boys and occasionally in girls. This is generally from sport or fall on an
outstretched hand. Not uncommonly, there is a delay in presentation, particu-
larly if the child is hesitant to report the injury to the family.
At presentation, the classic tenderness in the anatomic snuffbox region (Fig.
11-19) should be evaluated. AP, lateral, and scaphoid oblique view are helpful
to clarify the diagnosis. Scaphoid waist fractures certainly occur in the older
child and adolescent population. In addition, distal pole fractures are more
common than in adults.
Distal pole fractures can be treated in a below elbow thumb spica cast for ap-
proximately 6 weeks and then gentle return to activities.
Waist fractures are a bit more precarious (Fig. 11-20). If there is no displace-
ment, the injury appears stable, and swelling is mild to moderate, a below elbow
thumb spica cast can be applied for 4 weeks followed by radiographs, then re-
casting for an additional 4 weeks. If there is minimal displacement or a question
of stability, a long arm thumb spica cast should be applied for the first 6 weeks
followed by a short arm thumb spica cast for an additional 4 weeks.
In cases of delayed presentation, the scaphoid fracture anatomy is critical in
determining treatment. Despite having mild to moderate cystic changes in a
scaphoid fracture in a teenager, closed management can be successful with a
nondisplaced injury.
 The Boat-Shaped Bone

A navicular bone (shaped like a boat—from Latin navis ! ship, navicula ! small boat, skiff) is found in both the hand and
the foot. Rather than requiring one to clarify the hand navicular as a “carpal” navicular, most use the term scaphoid (from
Greek—scapho ! something dug or scooped out).

A CT scan is helpful in determining the anatomy of the scaphoid to look for

a humpback or flexion deformity. If the osseous alignment appears appropriate,
a course of closed management can be attempted prior to considering open
management.
.
Surgical treatment is indicated for a delayed union that shows no evidence of
.
healing, a displaced scaphoid fracture, and a scaphoid fracture that is associated
“The current method of
with carpal instability/ligament injuries (Fig. 11-21). The current method of choice for fixation of
choice for fixation of scaphoid fractures appears to be a variable pitch screw that scaphoid fractures appear to
provides compression as the screw is placed. This can be a cylindrical or tapered
design. In cases where there is delay in presentation and collapse of the be a variable pitch screw
scaphoid, bone grafting may be necessary to restore scaphoid anatomy. This can that provides compression as
be obtained from the iliac crest or the distal radius with care to avoid injury to
the distal radial physis.
the screw is placed”

Ligament Injuries
Although scapho-lunate injuries are not impossible, they are rare in children.
On the other hand, injuries such as the transscaphoid perilunate dislocation
have been reported in this age range.

At Injury After Open Reduction

Figure 11-21. This teenager had a serious fall in sports with a scaphoid fracture plus carpal dislocation.Treatment included open reduction,
stabilization of the dislocation with K-wires, and fixation of the scaphoid fracture with a variable pitch screw.

161
162 On rare occasion, in conjunction with other injuries of the distal radius or
Hand wrist region, ulna-sided wrist pain develops. This can be related to an ulnar sty-
loid nonunion, although complaints from this are rare.
Triangular fibrocartilaginous complex (TFCC) injuries occur in older chil-
dren. In cases of ulna-sided wrist pain with an unclear diagnosis, an arthrogram
At Injury contrast MRI of the wrist may delineate the pathology. This can be particularly
helpful in evaluating the TFCC. TFCC injuries may be amenable to arthro-
scopic evaluation and débridement versus repair, depending on the nature of
the injury.

CRUSH INJURIES—DIGITS
Crush injuries to the hand or digits can be difficult and challenging to treat
(Fig. 11-22). The severity of injury can range from the simple soft tissue contu-
sion and/or tuft fracture up through virtual or complete amputation of the
digit. The crush-injured digit tends to heal less well and over a longer period of
time than the digit that sustains an injury with a less severe mechanism. For
comminuted fractures, open reduction and internal fixation may be necessary.
One should anticipate a delay in healing and the need for pin placement for
a prolonged period of time, at least 6 weeks. The family should be counseled re-
garding the long-term prognosis and outcome from crush injuries. These in-
Intra-op clude poor nail development, stiffness, and/or angular deformity. Proper coun-
seling of the family should be undertaken preoperatively. Crush injuries to the
entire hand can also occur and management is simillar to what is done for adult
injuries. Release of compartments may be required in severe cases.

NERVE AND TENDON INJURIES

2 Months Post Op
Figure 11-22. This preschooler had a
television set dropped on his index finger.
His crush injury was treated with débride-
ment and pinning.
Both nerve and tendon lacerations can and do occur in children. The mecha-
nism tends to be from grasping and/or playing with sharp objects. Certainly, in
the older child, altercations with knives can be implicated. Halloween is a par-
ticularly risky time of the year (pumpkin carving is a slowly aquired skill).
Tendon repairs should be performed primarily. When the profundus and su-
perficialis tendon are disrupted, most likely only repair of the profundus is indi-
cated. Early occupational therapy is indicated in the older child, (perhaps age 6-
8). In younger patients, we use, a mitten-type cast with the wrist flexed 30°,
with the hand carefully positioned as if holding a ball but with nothing actually
within the hand. In such a cast, the child can volitionally wiggle the fingers
within the cast, although not generating any force of significance. Due to age,
detailed occupational therapy is not an option. Hence, the need to allow some
motion yet casted to avoid stressing the repair.

Suggested Readings
Barton NJ: Fractures of the phalanges of the
hand in children. Hand 1979;2:134-143.
Bogumill GP: A morphologic study of the
relationship of collateral ligaments to
growth plates in the digits. J Hand Surg
1983;8:74-79.
Campbell RM Jr. Operative treatment of
fractures and dislocations of the hand and
wrist region in children. Orthop Clin
North Am. 1990 Apr;21(2):217-43.
Dixon GL Jr, Moon NF: Rotational supra-
condylar fractures of the proximal pha-
lanx in children. Clin Orthop 1972;83:
151-156.
Fischer MD, McElfresh EC: Physeal and pe-
riphyseal injuries of the hand: Patterns of
injury and results of treatment. Hand
Clin 1994;10:287-301.
Hankin FM, Janda DH: Tendon and liga-
ment attachments in relationship to
growth plates in a child’s hand. J Hand
Surg 1989;14B:315-318.
Hastings H, Carroll C: Treatment of closed
articular fractures of the metacarpopha-
 langeal and proximal interphalangeal
joints. Hand Clinics 1988;4(3):503-527
Le TB, Hentz VR. Hand and wrist injuries
in young athletes. Hand Clin. 2000
Nov;16(4):597-607.
Leonard MH, Dubravcik P: Management of
fractured fingers in the child. Clin
Orhtop 1970;73:160-168.
Lester B, Jeong GK, Perry D, Spero L: A
simple effective splinting technique for
mallet finger. Am J Orthop. 2000 Mar;
29(3):202-6.
Mahabir RC, Kazemi AR, Cannon WG,
Courtemanche DJ. Pediatric hand frac-
tures: a review. Pediatr Emerg Care. 2001
Jun;17(3):153-6.
Mintzer CM, Waters PM. Surgical treatment
of pediatric scaphoid fracture nonunions.
J Pediatr Orthop. 1999 Mar-Apr;19(2):
236-9.
Moore RS Jr, Tan V, Dormans JP, Bozentka
DJ. Major pediatric hand trauma associ-
ated with fireworks. J Orthop Trauma.
2000 Aug;14(6):426-8.
Nofsinger CC, Wolfe SW. Common pedi-
atric hand fractures. Curr Opin Pediatr.
2002 Feb;14(1):42-5. Review.
163
 Pelvis and Hip
12
Maya Pring m Mercer Rang m Dennis Wenger

• Hip Dislocations 167

• Hip Fractures 169
• Pelvic Fractures 174
• Acetabular Fractures 178

INTRODUCTION
The osteoporotic bone of an elderly lady is very different from the tough, grow-
“We can be
ing bone of a child. Greater violence is required to produce a hip or pelvic frac-
ture in a child. For example, most trochanteric fractures are bumper injuries in
absolutely certain
children of 6 or 7 years, the age when the greater trochanter is at the level of a only about things
car bumper (Fig. 12-1), and most pelvic fractures are the result of high-speed
motor vehicle accidents. we do not
It is misleading to apply the mass of information about adult fractures to
children, and the small number of papers that relate specifically to children understand”
present widely varying statistics that are almost impossible to compare. If this
were a more common injury, perhaps we would all know more about the best —ERIC HOFFER
methods of treatment.
Luckily, unlike adults, children tolerate cast immobilization. The chance of
union is excellent in a young child with an undisplaced intertrochanteric hip
fracture. In a cast, a child will not develop bed sores or deep vein thrombosis or
lose the will to live, but malunion is a real hazard. If a displaced fracture of the
neck is reduced closed and held in a cast, coxa vara is almost a certainty.

Initial Exam
Occasionally, a child will fall from a countertop or the back of a couch and
strike the floor in just the right way, sustaining an isolated sub- or inter-
trochanteric femur fracture. However, more commonly, hip and pelvis fractures
165
166
Pelvis and Hip
Figure 12-1.Age determines the site of a
bumper fracture.
“Pelvic fractures may be
accompanied by
genitourinary and/or
gastrointestinal injury”
Figure 12-2. This child was run over by a
truck. Cystogram and retrograde urethro-
gram show complete disruption of the
urethra (arrow) and elevation of the blad-
der. Always remember to check for GI and
GU injuries when the pelvis is fractured.
in children are the result of high-energy violence and are associated with other
injuries. In these cases, the initial exam needs to concentrate on identifying any
life-threatening injuries including head, spine, thoracic, abdominal, pelvic, neu-
rologic, and vascular trauma. A coordinated plan to care for each injury must be
established. The hip exam itself must be gentle to avoid further disruption of
blood supply (especially femoral neck).
Associated Injuries
Pelvic fractures may be accompanied by genitourinary (GU) and/or gastroin-
testinal (GI) injury. It is important to look for blood at the urethral meatus and
to check for hematuria; a retrograde urethrogram/cystogram should be ob-
tained if clinically indicated (Fig. 12-2). Abdominal, vaginal, and rectal exams
are performed by or together with the general surgery team; blood at the anus
suggests injury to the lower GI tract that can contaminate a pelvic fracture; this
can be worse than an open pelvic fracture if missed. The rectal exam can also
identify a displaced prostate indicating transection of the urethra.
Specific Exam
Instability of the pelvis can often be felt with a compression test, testing for
both lateral and anteroposterior instability. This test should not be repeated by
multiple examiners as there is risk for compounding the damage already done
by the fracture. Feel the pulses and test active movements in both legs. Subtle
neurologic injuries are easily missed—always test sacral sensation. When the
sacroiliac (SI) joint is dislocated, the lumbosacral trunk, superior gluteal nerve,
and obturator nerve are at risk. However, as will be described later, children
rarely have true SI joint disruption, typically they fracture through the physis
adjacent to the SI joint. Sacral fractures can rupture the sacral roots, or the
foramina can be compressed causing compression of the sacral roots.
Blood Loss 167
Hip Dislocation
In the field, prior to arrival at the hospital, hemorrhage from a pelvic fracture can
often be partially controlled by binding the pelvis with a sheet wrapped tightly
around the patient at the level of the AIIS. This will close down fractures and tam-
ponade the bleeding during transport or until further treatment can be rendered.
Extraperitoneal hemorrhage to some degree is common and in most cases is
allowed to tamponade with blood transfusion given as needed. In a few in-
stances, bleeding can be massive and well concealed. An arteriogram may be re-
quired to identify the site of bleeding, and coils can be placed by the interven-
tional radiologist to stop the bleeding.

Reading Pelvic X-rays

The pelvis is a very complex three-dimensional structure and analyzing films
can be difficult. Fractures are difficult to see and can occur through growth
areas such as the triradiate cartilage, which makes x-ray interpretation difficult.
The ischio-pelvic syndesmosis is even more puzzling, and may mimic a frac-
ture (Fig. 12-3). This syndesmosis often fuses assymetrically, making interpreta-
tion difficult. Further complexity is added by Ogden’s noting that in very rare
instances this syndesmosis can be the site of a stress fracture in a young jogger.

Figure 12-3. A) In this young child, note

HIP DISLOCATION the ischium and pubis beginning to fuse. B)
In this older child, the synchondroses had
Dislocation is more common than femoral neck fracture in childhood and for- an almost expansile appearance. This is a
tunately carries far fewer risks for complications than does adult dislocation normal finding and should not be confused
(Fig. 12-4). This is likely due to hip joint laxity in the child as well as the fact that with a fracture. These syncondroses may
the acetabular growth cartilage (adjacent to labrum) is not yet ossified, with the true close asymmetrically, adding further confu-
socket not as deep as in the fully ossified adult. The hip of a child younger than the sion.
age of 5 is usually dislocated by a fall with minimal trauma. As age increases, the de-
gree of violence required to dislocate the hip escalates (age 6-10—athletic injuries,
automobile accidents thereafter). A more violent dislocation is more likely to be as-
sociated with fracture of the acetabulum or femur and sciatic nerve damage. Dislocation
A recent traumatic dislocation can hardly be confused with a long standing par-
alytic dislocation for which the treatment is entirely different. On the other hand,
recurrent dislocation of the hip in a child with Down’s syndrome may be confus-
ing. The bone looks normal, and only the classic facial features of Down’s syn-
drome clarify the diagnosis.

Classification
After Reduction
The femoral head can be dislocated either anteriorly or posteriorly or rarely into
the obturator foramen (Table 12-1). A hip is most commonly dislocated poste-
riorly causing the limb to be held in a shortened, flexed, adducted, and inter-
nally rotated position. Anterior dislocations cause the limb to extend, abduct,
and externally rotate. Traumatic obturator dislocations (or intrapelivc disloca-
tions) are very rare in children but have been reported. The hip tends to be held
Figure 12-4. This child dislocated his hip
in flexion, abduction, and external rotation, but this is more variable.
during a simple slip and fall. Reduction was
easy and protected with a hip spica for 4
Treatment weeks.

It is not merely kind to reduce a dislocated hip as soon as possible; early closed
reduction will almost always succeed, whereas each passing hour makes the
need for open reduction more likely (Fig. 12-5). Prompt reduction also reduces
the incidence for avascular necrosis (AVN) (although the incidence of AVN is
much lower in children as compared to adults).
168
Table 12-1 Hip Dislocations
Pelvis and Hip
Anterior
Hip extended abducted and externally
rotated
Figure 12-5. Complications recognized
after reduction. An acetabular fragment or
avulsion from the femoral head may block
complete reduction. A type I injury to the
physis may become evident.
At Injury
Figure 12-6. Following reduction, a widened joint space is indicative of a fragment in the joint. In this case, the arthrogram and subsequent
open reduction revealed an avulsion fragment of the femoral head with the attached ligamentum teres.
168
Posterior Obturator
Hip short, flexed, and internally rotated Hip flexed, abducted, and externally
rotated
Reduction of anterior and posterior dislocations are easy if adequate muscle
relaxant is used. A posterior dislocation is reduced by flexing the hip and the
knee to 90° and applying traction while the leg is externally rotated.
Anterior dislocation is best reduced by pulling the leg in extension, abduc-
tion, and internal rotation. After reduction, the hip should move freely without
crepitus. A post-reduction pelvis x-ray and CT scan should be obtained to con-
firm that the hip is concentrically reduced without intra-articular fragments.
The x-ray sign of fragment entrapment may be only a subtle joint space widen-
ing when comparing the injured to the normal hip.
After reduction, we apply a hip spica for 4 weeks to allow capsular healing.
Movement usually returns quickly, and myositis ossificans is rare in children.
Radiographic review should continue for a year to detect AVN.
Obturator dislocations should be taken to the operatinge room for open re-
duction. They are usually irreducible by closed methods.
Pitfalls
Problems are unusual. During a reduction, an unrecognized proximal femoral
epiphyseal separation may become apparent. In such a case, the neck, not the
head, reduces into the acetabulum. Such a circumstance mandates open reduc-
tion and pinning.
A trapped intra-articular fragment is easily overlooked if a post-reduction
CT scan is not obtained (Fig. 12-6). A fragment in the joint requires arthro-
After Closed Reduction
Avulsed Ligamentum Terres
tomy for removal of the fragment or fixation of large fragments. This can be a 169
posterior acetabular rim fragment, the ligamentum teres with an avulsed head Hip Fractures
fragment, or both.
The overall incidence of AVN in the literature is 10% or less. Delayed reduc-
tion and severe injury are the most important causes. Recurrent dislocation of
the hip is a rare sequel to traumatic dislocation.

Voluntary Dislocation of the Hip

Some teenaged girls complain that they can feel the hip dislocate. The usual
cause is a snapping hip, in which the tensor fascia lata jumps across the greater
trochanter as the girl rotates her hip. Once learned, some teenagers seem to
have a morbid preoccupation with repeating the maneuver. Some very convinc-
Adult
ingly impress the neophyte examiner as being a dislocation. Treatment is by Blood Supply
stretching (physical therapy) and only very, very rarely surgery (incision in ten-
sor fascia). An extremely rare cause is a true voluntary dislocation, a condition
that was described by Broudy and Scott.

HIP FRACTURES
Anatomy and Physiology—Hip
The following differentiate hip fractures in children as compared to adults:
1. The periosteal tube in a child is much stronger than in an adult; many frac-
tures are undisplaced in children. Child’s
2. The proximal femoral bone (with the exception of the physis) is much Blood Supply
stronger in children and requires a large force to break it, whereas the osteo-
porotic bone in the elderly is easily fractured with a simple fall.
3. The hardness of a child’s bone and the small diameter of the femoral neck
are often not suited to fixation with standard adult fixation devices. Figure 12-7. The adult has intraosseus
4. The proximal femoral physis is a point of weakness in the skeletally imma- vessels that supply the femoral head. Chil-
dren with open physes have a more tenu-
ture child; fractures that cross this growth plate may lead to physeal arrest ous blood supply as vessels do not cross
that can cause coxa breva or coxa vara. Although a fracture heals, deformity the physis.
may progress with growth.
5. The blood supply of the head is different (Fig. 12-7). When the physis is still
open, blood vessels do not cross the physis so the blood supply to the head is
tenuous and easily disrupted. AVN may result from complete division of the
vessels, kinking of the vessels that remain intact, or tamponade by
hemarthrosis within the hip capsule.

Classification
Pediatric hip fractures (from the femoral head to the lesser trochanter) have
been classified by Delbet (Table 12-2). More distal fractures of the femur in-
cluding subtrochanteric fractures are discussed in Chapter 8.

Treatment
Type I Fractures (Transphyseal)
The femoral head separates from the neck through the physis. In very young
children, this injury is most likely to occur when a child has been run over by a
car but may also be seen in abused infants. In children, great violence is re-
quired, and there are usually associated injuries. In adolescents, an acute Type I
170
Table 12-2 Delbet Classification of Pediatric Hip Fractures
Pelvis and Hip
Type I A Type I B Type II Type III Type IV

Transphyseal no Transphyseal with Transcervical Cervicotrochanteric Intertrochanteric

dislocation dislocation

injury is seen, which is difficult to differentiate from an acute (unstable) slipped

capital femoral epiphysis (SCFE) (see next section).
Traction has been advised for type IA fractures with no displacement in very
young children, but in most cases, spica cast immobilization is used. In dis-
placed fractures in infants, closed reduction is relatively easy, and the reduction
should be held in a one-and-a-half hip spica. Displacement can occur in the
cast, and frequent radiographs should be taken to detect this. If pin fixation is
At Injury
required (rare), it should be done with smooth pins because pinning may aggra-
vate the tendency for premature fusion.
If the head is dislocated (type IB), urgent open reduction is mandated (Fig.
12-8). Canale and Bourland described five cases of traumatic separation accom-
panied by dislocation and all developed AVN with four of the five developing
degenerative arthritis. The young patients required leg-length equalization.
Traumatic separation of the proximal femoral epiphysis is a severe injury, and
the parents should be warned that problems are more likely than not.

Type II and III Fractures—Transcervical and

Cervicotrochanteric
The perils of these injuries are great, with AVN reported in up to 50% of cases.
Although more common in displaced fractures, AVN can occur in undisplaced
fractures. Premature closure of the physis can occur as a sequel to AVN, leading
to a short femoral neck and a weak lever arm for the abductor muscles, a short
cross-table
view
neck
AVN After Open Reduction

head
Late Reconstruction

Figure 12-8. This 15-year-old boy suffered

a severe type IB injury with marked head
displacement. Despite immediate open re-
duction, he developed AVN. Late construc-
tion included femoral head recontouring,
bone grafting, and a shelf acetabuloplasty.
170
leg, and limitation of abduction owing to greater trochanter overgrowth (Fig. 171
12-8). Delayed union, nonunion, and drifting into coxa vara are also common. Hip Fractures

Nondisplaced Fractures
Nondisplaced neck fractures in young children (younger than 4 or 5 years) have At Injury
some inherent stability, and the safest way to protect them is in a one-and-one-
half hip spica with the leg held in internal rotation and abduction for 6-8
weeks. This is only advised for a truly undisplaced injury. The fracture should
be checked frequently for change in alignment. In older children, pinning is
technically easier and reduces the chances of displacement.

Displaced Fractures
Muscular forces across the hip joint tend to produce coxa vara in displaced frac- right left
tures (i.e., fractures in which the periosteum has been torn). Cast fixation after
reduction does not neutralize these muscular forces, and loss of reduction in a
spica cast is almost certain. For displaced fractures, the conservative approach is
internal fixation (Fig. 12-9). In the classic text Treatment of Fractures in Chil-
dren and Adolescents, Weber et al. state “We regard every fracture of the femoral
neck in a child as an emergency situation which requires operative intervention 6 Months Later
with a minimum of delay. Rapid action is essential to allow anatomically precise
reduction and stabilization as well as evacuation of the intracapsular
hematoma.” We adhere to this A-O recommendation for all displaced femoral
neck fractures. Although some surgeons might try a closed reduction and pin-
ning (as in treating an elderly patient), the open approach seems to provide the
most predictable results (Fig. 12-10).
The anterolateral or Watson-Jones approach gives excellent exposure for re- After Osteotomy
duction and fixation of femoral neck fractures. This approach utilizes the inter-
val between the tensor fascia lata and gluteus medius, with the abductors re-
tracted to expose the capsule. The capsule is opened to release the hematoma
and to allow exact fracture reduction. The fracture can be anatomically reduced
with the aid of a periosteal elevator, traction, and internal rotation. The fracture
is fixed with cancellous screws avoiding the physis if possible.
Most authors express a preference for threaded pin or screw fixation. The
metaphysis is composed of hard bone (unlike the adult metaphysis), providing a
“good bite” for screws or threaded pins. It is usually unnecessary to cross the ph-
ysis, but in high fractures do not hesitate to place a pin (temporarily) across the

Figure 12-10. Weber et al. emphazised
the need for urgent open reduction in this
injury (see Suggested Readings).An antero-
lateral Watson-Jones approach allows a
safe, extensive exposure to the capsule.
Hip
Capsule Figure 12-9. This 13-year-old boy fell on
wet grass and presented with a femoral
neck fracture. The bone scan showed de-
creased blood flow in the right hip. Despite
anatomic reduction and pinning, he devel-
oped mild AVN and coxa vara. Late treat-
ment included a valgus osteotomy.
Rectus
Femoris
Vastus
Lateralis
Figure 12-11.This intertrochanteric fracture in a 6-year-old child was treated with casting and went on to heal appropriately without surgi-
cal intervention.
Figure 12-12. Perisoteal stripping is the
suggested mechanism for femoral head AVN
secondary to greater trochanteric avulsion.
172
physis. If pins are placed across the physis, they should be smooth and be re-
moved as soon as possible to avoid interfering with growth. There are also sev-
eral lag screw-plate systems available now in children’s sizes. The capsule is
loosely closed once fixation is secure.
A child does not need rapid rehabilitation. Apply a hip spica for 6-8 weeks to
protect the hip (ruptured soft tissues—capsule, vessels) in hopes of decreasing
the chance for AVN. Remember the load on the hip imposed by straight leg
raising can approach that imposed by walking. A belt-and-suspenders approach
is needed to prevent nonunion, coxa vara, and AVN.
Type IV (Intertrochanteric Fractures)
In young children, most intertrochanteric fractures can be reduced and held in
skin traction. When callus is present at 3-4 weeks, a one-and-one-half hip spica
should be applied (Fig. 12-11). The chief indication for internal fixation is irre-
ducibility or inability to hold the fracture in traction because of other injuries.
Operative treatment used for older children can be difficult, because consid-
erable comminution or separation of the greater trochanter may be present
without being obvious on radiographs. Always obtain high-quality films before
starting surgery. Older children usually require ORIF with a plate and screws or
a lag screw with side plate.
Avulsion Fractures—Lesser Trochanter
Avulsion fractures of the proximal femur are not included in the previous classi-
fication system but are worthy of mention in this section. We frequently see
avulsion fractures in young aggressive athletes. Avulsion fractures of the lesser
trochanter can be caused by the pull of the iliopsoas in sprinters. These typically
heal with conservative treatment and do not result in noticeable hip flexor
weakness. Crutch use and partial weight bearing for 3-4 weeks typically gets
athletes back into competition.
Avulsion Fractures—Greater Trochanter
The greater trochanter can be avulsed by the abductors, usually associated with
a severe twisting fall (Fig. 12-12). Although this injury may appear relatively be-
nign, the posterior circumflex vessels traverse dangerously close to the fracture
plane and may be disrupted at the time of fracture (probably in relation to asso-
ciated periosteal stripping). If the fracture is allowed to heal in a significantly
displaced position, the abductors will be weak and Trendelenburg limp will re-
sult. ORIF is the preferred method of treatment for displaced fractures; how-
ever, the technique should be cautious to avoid increasing the risk for AVN of
the femoral head (which is substantial) (Fig. 12-13).
Pitfalls 173
Hip Fractures
Ratliff emphasized AVN as the main cause of poor results in proximal femoral
fractures (Table 12-3). MacEwen reports that type IB injuries (complete head
separation and dislocation) have the highest rate of AVN (80-100%), followed
by type IA and type II (50%), and type III (27%). Type IV (intertrochanteric)
fractures have the lowest reported rate of AVN (14%).
AVN is best detected early with a bone scan or MRI but is often apparent ra-
diographically after several months and probably always within a year. Radi-
ographs should be obtained regularly (every 2-3 months) during the first year.
The first x-ray signs of AVN include the head does not become osteoporotic
and does not grow, and the cartilage space becomes wider. These signs appear
long before signs of gross density, fragmentation, and deformity of the head.
Slight disturbance of circulation produces coxa magna luxans creating a large
head that is poorly covered by the acetabulum.
Coxa vara is the most common deformity following cast treatment of proxi-
mal femoral fractures; it results in a shortened limb and abductor weakness and
may predispose to future fractures of the femoral neck.
Nonunion is rare, but when it occurs, bone grafting is advocated with valgus
osteotomy if there is coxa vara.

SCFE (vs.Transphyseal Fracture)

As noted before, an acute SCFE and a type 1A transphyseal fracture are similar
images by x-ray but occur in different patient populations. Ratliff noted that
acute fractures occur up until age 8-9 years and that acute (unstable) slips occur
in teenagers, often with predisposed anatomy (obesity, retroversion of the
femoral neck—Table 12-4). SCFE, a pathologic process and not necessarily the
result of trauma, will be discussed here because it is within the spectrum of phy-
seal fractures. In the most basic terms, SCFE is the result of a “sick” physis that
Figure 12-13. An avulsion of the greater
is unable to support the weight of the child. The femoral neck becomes progres- trochanter can result in AVN of the
sively more retroverted until the femoral head slides off the neck through the femoral head.
physis. The trauma that is associated with an acute SCFE is typically less severe
than the trauma required to fracture a healthy proximal femur.

Classification
SCFEs are traditionally classified as acute (pain !2 weeks), chronic (pain "2
weeks) or acute on chronic (sudden worsening of chronic pain).

Table 12-3 Ratliff Femoral Head AVN Classification

Type I Type II Type III

AVN of the head and neck proximal AVN of the head alone (22%) AVN of the neck alone (18%)
to the fracture (60%)
174 Table 12-4 Differentiating a Fracture from a Slip
Pelvis and Hip (modeled from Ratliff)
Transphyseal Slipped Capital
Characteristic Fracture Femoral Epiphysis
Age incidence Child under 9 y/o Child 11–16 y/o
Onset Sudden, following injury Gradual or sudden
Mechanism of Severe violence, e.g., MVA No injury or minor violence,
injury e.g., fall
Endocrine defect Not present Sometimes present

MVA # motor vehicle accident.

At Presentation Loder modified this into a patient presentation classification describing

SCFE as being either stable or unstable. A patient is able to walk unassisted
with a stable slip (this correlates to a chronic slip in the traditional classifica-
tion). Patients with unstable SCFEs are unable to walk due to acute pain (these
correlate to acute and acute on chronic SCFE).

Treatment—SCFE
In situ pinning with screws or threaded Steinmann pins is the standard treat-
ment for stable SCFE (Fig 12-14); treatment of the acute (unstable) injury is
more difficult and is heavily debated. The tradition was to try traction followed
by pin fixation, but this method still led to a high AVN rate. One should con-
sider an aggressive approach that includes emergent open reduction and fixation
with threaded screws. Parsch (Stuttgart) emphasizes that open inspection allows
reduction to just the right position (avoiding over-reduction) in cases of acute on
chronic slip. We favor this approach, which appears to decrease the risk of AVN
(Fig. 12-15). The surgical approach is similar to that discussed for open reduc-
tion of childhood femoral neck fractures (discussed earlier in this chapter).
After Pinning

PELVIC AND ACETABULAR FRACTURES

The pelvis is like a suit of armor: when it is damaged there is much more con-
cern about its contents than about the structure itself. The problems for the or-
thopedic surgeon are different at each age. Osteoporotic old people sustain
minor fractures in falls that pose neither visceral nor orthopedic problems.
Young adults involved in motor vehicle accidents (MVAs) suffer fractures that

Figure 12-14. This patient presented

with a left chronic SCFE and a right acute
on chronic SCFE. Both were treated with
in situ pinning.
Figure 12-15. This acute SCFE was treated with open reduction and internal fixation.
Acute slips are at extremely high risk for AVN.
may be difficult to reduce in addition to life-threatening visceral injuries. Chil- 175
dren’s fractures are seldom displaced much and can usually be treated with rest Pelvic and Acetabular Fractures
and protected weight bearing, but their other injuries may require more atten-
tion. On the other hand, teenagers often have severe fractures (Fig. 12-16).

Radiographic Issues
Avoid ordering a frog view of the pelvis if there is any concern for a hip fracture.
Although this is the lateral view of the proximal femur that orthopedic surgeons
are accustomed to, placing the child in a frog position risks further displace-
ment of a hip fracture. Instead, order a cross-table lateral (along with an AP
pelvis view) for safe radiographic evaluation.
Pelvic ring fractures are better evaluated with inlet and outlet x-rays (tube
angled 45° caudad or cephalad, respectively) in addition to the AP view (Fig.
Figure 12-16. This patient was in a se-
12-17). vere MVA, he sustained a left femur frac-
Acetabular fractures are initially evaluated with oblique (Judet) x-rays. The ture as well as a vertical shear fracture to
obturator oblique x-ray allows evaluation of the anterior column and the poste- his pelvis, fracturing through his SI joint, is-
rior rim of the acetabulum. The iliac oblique shows the posterior column and chium, and pubis on the left side.
the anterior rim. However, a three-dimensional CT scan is much more accurate
and is becoming a standard for evaluation and preoperative planning (if surgery
is being considered).

Judet X-rays of the Acetabulum Inlet View—Helps in Assessing Posterior

Ring Pathology
Iliac oblique Obturator oblique

Outlet View—Demonstrates Anterior

Ring Pathology

Posterior Anterior
column column

Posterior
rim
Anterior
rim

The Judet brothers of Paris were among the best known 20th century
orthopedic surgeons.They made important contibutions to the develop-
ment of total hip arthroplasty but in addition were experts in diagnosing
and treating acetabular fractures.Their classic paper introduced English
language readers to the proper radiographs needed to assess acetabular Figure 12-17. Inlet and outlet views show
and pelvic fractures. Much can be learned by analyzing these oblique any disruption of the pelvic ring and they
views (although CT scans have diminished their mystique). are especially good for seeing movement
of the SI joint.
176 A gonadal shield should not be used when obtaining x-rays of possible pelvic
Pelvis and Hip fractures—the pathology can easily be concealed by the shield.
MRI studies are rarely needed but when performed have shown interesting
differences in adult versus children’s SI joint injuries. MRI studies of posterior
pelvic injuries have clarified that the vertical displacement in SI joint injuries in
children occurs through the non-ossified iliac growth cartilage next to the SI
joint and typically does not tear the ligaments, analogous to what one sees at
the ankle in a child (physeal separation rather than ligament injury). Thus bony
healing is likely in children.

Classification
The most important aspect of understanding pelvic fractures is whether the
fracture is stable or unstable. This differentiation provides the basis for whether
a pelvic fracture will require operative intervention. A single break in the pelvic
ring typically does not render instability to the pelvis; two or more breaks in the
ring will destabilize it.
Quinby and Rang classified pelvic ring fractures into three groups:
Group I: Uncomplicated fractures; these are minor and minimally dis-
placed. Signs of abdominal or urologic injury are absent or settle
quickly with non-operative treatment.
Group II: Fractures with visceral injuries requiring surgical exploration.
These are more severe; the patient may be in shock and require
transfusion. The pelvis can conceal a large amount of hemorrhage
before it is clinically apparent.
Group III: Fractures associated with immediate massive hemorrhage. Hemor-
rhage may be from visceral injuries or vascular injury. Even with
advanced trauma life support and aggressive management, the
mortality of these patients is still high.
Torode and Zieg developed a more detailed classification system for pediatric
pelvic fractures, which is summarized in Table 12-5.

Figure 12-18. Many muscles originate at
the pelvis.With strong muscle contraction,
the origin of the muscle can be avulsed.
Treatment
Avulsion Fractures About the Pelvis
With today’s aggressive athletics, the muscles about the hip often overpower the
open pelvic apophyses creating avulsion fractures (Fig. 12-18).

Table 12-5 Torode and Zieg Classification of Pelvic Fractures

Type I Type II Type III Type IV

Avulsion fractures Iliac wing fractures Simple ring fractures (includes Fractures producing an
pubic and acetabular fractures) unstable segment, (includes
straddle, Malgaine, and other
unstable fractures)
TECHNIQUE TIPS: 177
Two Types of ASIS Avulsion Injuries Pelvic and Acetabular Fractures

Type I—Sartorius Avulsion

(Sprinting Injury)

Type II—Tensor Fascia Avulsion

(Rotational Injury)

Drawings courtesy of Scott Mubarak.

178
Pelvis and Hip
Figure 12-19. This multi-trauma patient
was treated with SI joint fixation and an
external fixator for his pelvic ring fracture
as well as a nail for his subtrochanteric
fracture.
! The iliac crest apophysis can be avulsed by aggressive twisting as seen in
baseball batters.
! The anterior inferior iliac spine is avulsed by the rectus femoris (often seen
in soccer and rugby players).
! The anterior superior iliac spine can be avulsed by the sartorius or the tensor
fascia lata (seen frequently in sprinters).
! The ischium can be avulsed by the hamstrings (most commonly in hurdlers
and gymnasts).
The vast majority of these avulsion fractures heal very well with conservative
treatment including protected weight bearing for 3-4 weeks. A very rare patient
will develop a painful nonunion that requires operative fixation or excision of
the fragment; this is not the first line of treatment.
Fractures of the Pelvic Ring
Stable fractures of the pelvic ring (rami fractures, iliac wing fractures, ishial frac-
tures) that do not involve a joint (acetabulum or SI joint) and are not associated
with hemorrhage can typically be treated with a few days of rest followed by
protected weight bearing until the fracture heals (usually 4-6 weeks).
Unstable pelvic fractures can be fixed with an external fixator or internal fix-
ation. Pin placement for the external fixator will depend on the location of the
fracture and the unstable segment. All orthopedic surgeons should be able to
quickly apply a stabilizing pelvic external fixator. These should be positioned to
allow access to the abdomen if the general surgeons are planning surgery for a
visceral injury.
Many pelvic fractures are now fixed with percutaneous screws. These are very
useful for fractures involving the sacroiliac joint, superior ramii, and some iliac
wing fractures, but due to the complexity of understanding the three-dimen-
sionality of the pelvis, this percutaneous approach is best left to the experts (Fig.
12-19).
ACETABULAR FRACTURES
Fractures of the acetabulum in the skeletally immature patient are extremely
rare. When they occur, they are typically seen as separation through the tri-radi-
ate cartilage. With minimal displacement, fractures of the tri-radiate cartilage
can be treated with protected weight bearing; this fracture risks closure of the
tri-radiate growth center and subsequent hip dysplasia. Fractures with signifi-
cant displacement need to be reduced. Smooth pins can cross the tri-radiate car-
tilage to maintain reduction and should be removed once the fracture is healed
to avoid iatrogenic closure.
Once the tri-radiate cartilage closes, fractures of the acetabulum are classified
and treated like adult fractures. Three-dimensional CT scan is very useful for
understanding the fracture. It is critical to remove any bone or cartilage frag-
ments from the hip joint to avoid further joint destruction. Reconstruction of
the acetabulum is best left to the experts; traction is often useful to keep the
joint distracted until the time of surgery.
CONCLUSION
Luckily, hip and pelvic fractures are relatively rare in children. It is important to
understand and recognize these fractures and their associated injuries. The more
severe fractures are produced by high-energy trauma and the associated injuries
may be life threatening. Proximal femoral fractures need to be maintained in
anatomic alignment until the fracture has healed. The risk of AVN is significant
following both closed and open treatment of proximal femoral fractures. In the
rare instance that a pelvic fracture requires operative intervention, this may be
best left to the experts as the surgery may be technically difficult and the prog-
nosis is often poor.
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Davison BL, Weinstein SL. Hip fractures in
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Flynn JM, Wong KL, Yeh GL, Meyer JS,
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Grisoni N, Connor S, Marsh E, Thompson
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Hughes LO, Beaty JH. Fractures of the head
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Joint Surg Am. 1994 Feb;76(2):283-92.
Judet R, Judet J, Letournel E. Fractures of
the acetabulum: Classification and surgi-
cal approaches for open reduction. Pre-
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1964 Dec;46:1615-46
Magid D, Fishman EK, Ney DR, Kuhlman
JE, Frantz KM, Sponseller PD. Acetabu-
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Sep-Oct;12(5):621-5.
Mehlman CT, Hubbard GW, Crawford AH,
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(376):68-79.
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1985 Sep-Oct;13(5):349-58.
Morsy HA. Complications of fracture of the
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term follow-up study. Injury. 2001 Jan;
32(1):45-51
Musemeche CA, Fischer RP, Cotler HB, An-
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538-40.
Nikolopoulos KE, Papadakis SA, Kateros
KT, Themistocleous GS, Vlamis JA, Pa-
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525-8.
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O’Rourke MR, Weinstein SL. Osteonecrosis
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Oct;85-A(10):2000-5
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term outcome in children with fractures
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trauma. J Trauma. 1999 Jan;46(1):58-64.
Ratliff, AHC: Traumatic separations of the
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Scuderi G, Bronson MJ. Triradiate cartilage
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Silber JS, Flynn JM. Changing patterns of
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Smith WR, Oakley M, Morgan SJ. Pediatric
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Jan-Feb;24(1):130-5.
Song KS, Kim YS, Sohn SW, Ogden JA.
Arthrotomy and open reduction of the
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10(3):205-10.
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 Femoral Shaft
13
Maya Pring m Peter Newton m Mercer Rang

• Assessing the Patient 181

• Radiographic Issues 182
• Classification 183
• Treatment 184
– 0-2 Years
– 2-6 Years
– 6-12 Years
– 14 Years and Older
– Alternative Treatment Methods
• Acceptable Results 197
“The surest way to
corrupt a young
INTRODUCTION
man is to teach
Femur fractures in children are common, with causes ranging from abuse in a
neonate to a motorcycle accident in a 16-year-old. Optimal treatment varies ac- him to esteem more
cording to age (Fig. 13-1). Surgeons who treat children’s fractures need to un-
derstand the nature of a femoral fracture in each age group and master treat- highly those who
ment techniques that allow full recovery of structure and function. In this
chapter, we will divide femoral fractures into age groups and present a practical
think alike then
treatment path for each group. those who think
ASSESSING THE PATIENT differently”
In most cases, diagnosis of a fractured femur is straight-forward. After the pedal —NIETZSCHE
pulses have been palpated, the leg should be splinted before radiographs are
181
182
Femoral Shaft
“Surgeons who treat
children’s fractures need to
understand the nature of a
femoral fracture in each age
group and master treatment
techniques that allow full
recovery of structure and
function”
A B C
Figure 13-1. Each fracture must be treated Figure 13-2. A fracture may appear dis-
differently based on the age of the child and tracted or overlapping depending on the
the anatomy of the fracture. A) Spiral frac- angle at which the radiograph is taken. Judge
ture in infancy, easy to hold in a cast. B) length with a tape measure.
Proximal fracture in an 8-year-old, hard to
hold in cast. C) Shaft fracture in a teenager,
will require intermedullary fixation.
taken. A subsequent thorough physical exam and secondary survey are critical
because the pain of a femur fracture frequently distracts the patient who may
not complain of other possibly life-threatening injuries. Monitor the blood
pressure; shock is almost never the result of a femur fracture in childhood and is
more likely due to internal hemorrhage (e.g., a ruptured spleen).
Although femur fractures are common and may result from apparently min-
imal trauma or a twisting injury during ordinary play, if the child is younger
than age 5 years, nonaccidental trauma or child abuse should be considered. If
there is concern, a skeletal survey and ophthalmologic exam should be obtained
with child protection services involved in the evaluation (see Chapter 17). In a
study by Nurk et al., 67% of femoral fractures in children younger than the age
of 1 year were secondary to child abuse. However, patients between 1-2 years of
age were much more likely to sustain their femur fractures through nonabuse
mechanisms; only 11% of children age 1-2 sustained fractures from abuse. An
orthopedic surgeon’s experience in noting that roughhouse play among siblings
can lead to an innocent limb fracture in a young child (and that spiral fractures
are very common in nonabuse circumstances) can often add clarity to the initial
social service inquiry of child abuse.
RADIOGRAPHIC ISSUES
Often, the initial femur film is not of high quality, being one of many x-rays
taken quickly in the emergency department as opposed to the more controlled
setting of the radiology suite. Polytrauma patients can be difficult to position,
and with the many issues that take precedence in their acute medical manage-
ment true AP and lateral x-rays are unusual.
However, several things can be learned from these early films (location of frac-
ture, angulation, shortening, etc.), and decisions for treatment can usually be
made based on these initial films despite their shortcomings. One must be certain
that the x-rays include both the hip and knee prior to proceeding with treatment
to avoid missing a hip dislocation, femoral neck fracture, or occult knee injury.
The degree of fracture shortening or fragment overlap at the time of initial in-
jury has been used to help determine appropriate management. Staheli has noted
that the markedly shortened limb (due to fracture overlap) is not a good candidate 183
for early spica treatment; however, the concept of initial shortening as a determi- Classification
nant of treatment choice cannot be easily applied for several reasons. Figure 13-2
describes the difficulty in assessing fracture distraction or overlap on plain films,
both at the time of initial evaluation and later with the patient in traction or a spica
cast. The lateral radiograph may be more accurate in assessing true shortening. “Modern EMT transport
Modern emergency medical treatment (EMT) transport includes application includes application of
of traction in the field (Fig. 13-3), which makes determination of initial shorten-
ing (and associated periosteal stripping) difficult. Some have suggested a manual
traction in the field, which
“push test” to determine how much the fracture will shorten. However, this is makes determination of
painful for the awake child and may risk further soft tissue damage; traction initial shortening (and
should generally not be removed for x-rays or exam until adequate sedation and
analgesia have been obtained. associated periosteal
As casting techniques have improved (Chapter 5), we have moved away from stripping) difficult”
the concept of initial shortening as an indicator for traction and cast many
femoral shaft fractures that were previously thought not amenable to early spica
treatment. Vigilance regarding observation for subsequent in-cast shortening
must accompany this approach.

CLASSIFICATION
Several classification methods help determine appropriate treatment for each
femur fracture type.

Anatomic Classification
Femoral shaft fractures are typically divided into proximal (subtrochanteric),
midshaft, and distal types. (Femoral neck and hip fractures are discussed in Figure 13-3. For quick transport of a pa-
Chapter 12; distal physeal and epiphyseal fractures in Chapter 14.) tient with a femur fracture, a Harris trac-
tion splint can be used to keep the fracture
out to length.These splints cannot be used
Deformity Classification for more than a few hours as there is a risk
of skin necrosis and tourniquet effect at
Depending on fracture level, the forces exerted on the fragments by the muscles the ankle.The proximal pad pushes against
that remain attached can pull the fracture into varus, valgus, flexion, extension, the ischium while traction is pulled
.
or rotational malalignment (Fig. 13-4). These forces must be considered and through the ankle cuff.

Proximal Midshaft Distal

Risk for varus, flexion and Risk for rotational and angular Risk for knee malalignment
external rotation deformity and recurvatum

Figure 13-4. A deformity of the fracture will be based on the anatomic location of the fracture.
184
Femoral Shaft
“The drama facing the
parents of an infant with a
fractured femur who requires
hip spica immobilization
cannot be overestimated”
Table 13-1 Simple Treatment Outline—According to Age
Standard Options for More Complex
Age of Child Treatment or Open Fractures
!2 years Single leg spica, or Pavlik harness Skin traction with delayed casting
2–6 years Early spica cast Skin or skeletal traction, plate
fixation (submuscular or open), ex-
ternal fixator
6–14 years Flexible intramedullary nails Skeletal traction, plate fixation (sub-
muscular or open), external fixator
"14 years Interlocked intramedullary nails Skeletal traction, plate fixation (sub-
muscular or open), external fixator
counteracted by the cast, traction, or internal fixation when planning treat-
ment. Poorly applied treatment of any type can worsen the initial deformity
and create an unacceptable result.
Age-Based Classification
Contemporary treatment methods have allowed development of an age-related
treatment algorithm (Table 13-1) appropriate for institutions where current
technology is available and who have an incentive to shorten hospital stays. This
algorithm will obviously differ in hospitals where flexible nails and trochanteric
entry nails are not available and where lengthy hospital stays (in traction) are
more affordable than the latest technology. Traction remains a viable and fre-
quently used treatment method for femoral shaft fractures in any age group.
The reader should recognize that the age cutoffs in this algorithm are not ab-
solute with treatment of each child tailored to the size and activity level of the
individual. For example, a 130-pound 6-year-old skateboarder will be treated
differently then a 70-pound gymnast of the same age. Larger patients are diffi-
cult to manage in a spica and are more likely to be treated surgically.
TREATMENT
Children Age 0-2 Years
Because fractures heal readily at this age and have great potential for remodel-
ing, a good outcome is almost certain in very young children regardless of
shortening or initial alignment. Surgery is almost never necessary (the rare ex-
ceptions being an open fracture or fracture with neurovascular compromise).
Treatment choices for the infant include a Pavlik harness or a hip spica cast.
(Fig. 13-5). In very young children, often the Pavlik harness provides adequate
immobilization and the traditional single leg spica is not required, which greatly
simplifies diaper changing and overall care of the child.
The drama facing the parents of an infant with a fractured femur who re-
quires hip spica immobilization cannot be overestimated. Imagine young par-
ents who are panicked about their child’s injury and who may in addition feel
that they are being accused of child abuse: it takes an experienced, mature team
to handle this circumstance gracefully.
The surgeon must consider many issues including:
• Where to apply the spica cast (emergency department, clinic, OR),
• Whether the parents should be present for the spica application (if in clinic
or emergency department)
 Date of Injury 2 Weeks 2 Months

Figure 13-5. This infant was treated in a Pavlik harness and had quick healing and remodeling of her fracture.

• The need for and advisability of sedation

• Whether the child should be admitted to the hospital for further workup,
monitoring, or family teaching about care of the child in a hip spica
Whether this is done awkwardly or well depends on the orchestration of the
team leader.
Although an infant with a femoral fracture and newly applied hip spica can
be sent home following casting, we have concerns about this concept. Caring
for a child of any age in a hip spica is an immense new burden on the parents,
and clear instructions are required for the parents to understand cast care, dia-
pering, carrying the child, wheelchair rental and use, etc. We believe that most
parents of a child with a new hip spica require careful instruction and teaching,
and in our system this is most likely to occur with an overnight hospital admis-
sion. Exceptions might include an early morning case where teaching nurses
can then provide education during the day.

Application of Hip Spica Cast

Very young children (up to age 2 years) who require little manipulative reduc-
tion can have a spica cast applied in the emergency department or clinic, fre-
quently with no sedation or with only minor conscious sedation. Remember
that early spica application may prevent overall inspection of the child (abdom-
inal viscera, skin bruising, etc.) and should be avoided if a child abuse workup is
Figure 13-6. Typical spica cast position
ongoing. The spica should be easy to apply with the child awake and in a posi-
for a young child.
tion that makes care of the child as simple as possible. Usually, the hip is flexed
30° and abducted 30° with the knee in similar flexion (Fig. 13-6).

Children Age 2-6 Years “We avoid the term

‘immediate spica’ treatment
In this age group, most femoral fractures can be treated with manipulative reduction
plus a hip spica cast, commonly referred to as “immediate spica” cast treatment; we as it implies a sometimes
avoid this terminology because it implies that both the patient and the doctor are unnecessary rush to
best served by applying the spica cast immediately. We prefer the term “early spica”
treatment and often find it better for all involved to admit the child for temporary
treatment. Often temporary
placement in skin traction (see Techniques Tips—Skin Traction) until the dust has traction with spica
settled. This allows assessment of swelling and possible associated abdominal or application at a scheduled
other soft tissue trauma, as well as allowing the surgeon to perform the reduction
and hip spica application in a comfortable environment at an elective time with an time with ‘daytime’
experienced team. This is usually within the first few days after injury. personnel is better”
185
186
Femoral Shaft TECHNIQUE TIPS:
Skin Traction

1. For patients "60 pounds

2. Apply adhesive to the skin
3. Pad malleoli and fibular head with cast padding
4. Apply traction tape (fabric-backed foam) down me-
dial and lateral sides of the leg
5. Overwrap the tapes from ankle to knee leaving the
foot free
6. Use no more than 5 pounds of weight
7. Use sling or pillow to support the hip and knee in a
slightly flexed position (20˚-30˚)
8. Check skin regularly, as skin blistering and sloughing
can occur
9. Regular neurovascular checks—nerves and blood
vessels can be compromised
10. Traction used until adequate callus for spica

TECHNIQUE TIPS:
Skeletal Traction

1. For patients "60 pounds (can be used on adults as well as chil-

dren)
2. The distal femur is preferred for insertion of Steinmann pin
(tibial pins may sublux the tibia and stretch the knee ligaments
or injure the tibial tubercle)
3. Pins may be threaded (better hold) or smooth (easier to insert
and remove)
4. Pins inserted from medial to lateral to protect the neurovascu-
lar structures, entry point is proximal and parallel to the physis
in the metaphyseal flare
5. During pin insertion, hold the leg in the position for traction
(usually 90-90) so the skin and fascia are not stretched after
pin insertion
6. Apply dressing over pins, followed by a traction bow
7. A short leg cast with anterior loops allows rotation adjustment
and prevents equinus contractures
8. Apply enough weight to support the leg, avoid over distraction
at the fracture site
9. X-rays in traction should be checked weekly to allow proper
adjustment of weight and position to ensure that there is no
distraction at the fracture site and that alignment remains ac-
ceptable
10. Traction used until adequate callus for spica (good test: no
pain with thigh motion—usually 3 weeks)
 This age group requires greater attention to reduction than does the infant, 187
thus fracture classification becomes more relevant. The goal of manipulative re- Treatment
duction plus spica cast application is to align the distal and proximal fragments
in a position most likely to be maintained by the cast (Fig. 13-7). The surgeon
must skillfully mold the cast to counteract the forces of the muscles that pull on
each fragment.
End-to-end reduction, which is difficult to achieve, is not required because
the femur tends to overgrow following fracture. Initial in-cast shortening of
1-1.5 cm is ideal and up to 2-3 cm is often acceptable.

Proximal Fractures
Proximal femoral fractures often prove difficult to align in a spica cast and may
require traction or open reduction plus internal fixation. The strong pull of the
abductors and external rotators on the greater trochanter pulls the proximal
fragment upward and outward. Whether treated in traction or attempted early
spica reduction, these patients should be treated with the hip in flexion, abduc-
tion, and external rotation to align the shaft with the proximal fragment (90-90
position with the heel over the contralateral tibia). The parents should be
warned at the outset that treatment may change. If reduction is lost, the patient
may need to be converted to traction or even open reduction and internal fixa- Figure 13-7. Young children have an in-
tion to optimize the outcome (Fig. 13-8). credible potential to remodel femur frac-
tures. Fractures need only to be aligned in
Mid-shaft Fractures the cast not necessarily reduced.

Midshaft fractures tend to drift into varus so the cast should be aggressively
molded to create slight valgus initially. It is important to evaluate rotation of the
fracture both clinically and radiographically as the proximal fragment will tend
to externally rotate.

Cast Position—90°-90° Versus Relative Extension

Twenty years ago, the 90°-90° (hip-knee flexion) cast position became popular
(Arkansas Children’s Hospital method). The foot/calf segment and abdominal
segment were applied first with the two segments then connected (using trac-
tion on the distal casted tibia). Although effective in maintaining reduction,
Frick as well as Czertak have reported skin problems as well as compartment

At Injury In Traction In Spica After ORIF

90°-90° casts have been associated

Figure 13-8. Treatment may need to be changed during the course of healing. This patient with severe skin problems and com-
was initially treated in traction for 3 weeks and then converted to a spica cast.The cast did not partment syndromes (see Chapter 5).
maintain the fracture alignment and the family opted for surgery instead of continued traction.
188
Femoral Shaft
“Proximal femoral fractures
often prove difficult to align
in a spica cast and may
require traction or open
reduction plus internal
fixation”
Figure 13-9. Angulation at the fracture site can be treated with wedging of
the cast.
syndromes and skin slough associated with this method. We no longer use the
strict 90°-90° position to avoid these risks (also see Chapter 5).
Distal Fractures
For distal fractures, the gastrocnemius tends to flex the distal fragment, causing
recurvatum at the fracture site. Flexing the knee will reduce this deforming
force. Distal femoral fractures can be aligned with a neutral varus-valgus align-
ment—with the knee in 10°-20° of flexion. Because of the increased risk for
knee malalignment in distal fractures, x-rays should include the proximal tibia
to ensure proper positioning in the cast.
Following the Patient—Pitfalls
Early spica treatment is efficient but may blind the surgeon to evolving com-
plications. Changing a selected course goes against the “black and white” nature
of many surgeons. Gradual angulation or shortening in the spica must be recog-
nized and dealt with if the reduction becomes unacceptable. The wise surgeon
must be flexible and react promptly to changes.
Response to progressive shortening or angulation may include:
! Cast wedging (Fig. 13-9)
! Change to traction
! External fixator application
! Open reduction
Changing to traction or an external fixator is always easier if the parents have
been warned of the possible need to return to more traditional methods.
Duration of Treatment
Spica cast immobilization should continue until healing is evident on x-ray; a
ball-park rule for weeks of casting is 3 + the child’s age in years, up to 12 weeks
(e.g., a 4-year-old child is casted for approximately 7 weeks). The fracture
should be monitored with weekly x-rays for the first 3 weeks. Because the evolv-
ing callus is flexible during this time period, moderate loss of alignment can
often be corrected by careful cast wedging.
In Spica Cast Wedged At Cast
Removal
TECHNIQUE TIPS: 189
Application of a Hip Spica for Child with Treatment

Femur Fracture

(Cast in relative extension minimizes risk to skin and compartments)

.

1) Short leg (below knee segment) ap- 2) Limb positioned in relative exten- 3) Synthetic material rolled on. Again
plied first to help hold the limb. Little sion. Cast padding added. Note tempo- note cast prominence over temporary
traction or pressure can be used and rary spacers under padding over ab- abdominal protection spacers.
the junction must be well padded (we domen (use towels or skin tape packs).
use felt). Some do not incorporate the
foot and add the calf segment last (to
avoid skin problems).

4) Fiberglass completed.
5) View from above—cast complete— 6) Spica cast complete; abdominal pads
note cast has been trimmed down to removed. Wood is attached to oppo-
the umbilicus level to ensure easy ab- site thigh for stability.
dominal expansion and breathing—The
temporary pads will now be removed
(once cast hardens).
Pre-Spica film After Spica

NOTE: We have changed to this more relaxed position, as compared to the

90°-90˚ position, which has a risk for skin and compartment problems in the
calf. Some would not apply the calf segment first nor incorporate the foot to
further minimize these risks.
190 Activity Level After Spica Removal
Femoral Shaft
Advice for return to activity is perhaps the least standardized part of childhood
femoral fracture treatment. Should children use crutches and at what age is
crutch training appropriate? Do children fall more and put themselves at higher
risk of refracture with crutches? Does physical therapy help? There are no defin-
Time in Hip Spica
itive answers, but we will present our observations and recommendations.
for Femoral One can never be sure of the strength of the callus visualized on the immedi-
Fractures ate post spica x-ray. (Fig. 13-10) How strong is it? Is there any risk that the
Ball-park rule femur may bend with weight bearing? When the spica is removed, we describe
3 # child’s age in years the fracture as “healing,” not healed, accordingly, we advise the parents as fol-
$ time in cast lows:
(up to a total of 12 weeks) ! Each child has an individual healing biology
! We don’t know when the child will walk (it could be 2 days or several weeks)
For example: 6-year-old child ! Take the child home and let him/her sit on the floor and crawl
$ 9 weeks in spica ! Do not help or encourage the child to walk
! Allow to pull to stand when able
6 Weeks After Injury ! The child will gradually progress to walking and will limp for several months
! Crutches are generally not necessary in this young age group and are poorly
tolerated in children younger than 6 to 7 years old
! Physical therapy does not appear to change the outcome

Children Age 6-12 Years

Shortening and malunion are the main risks in this age group because of in-
creasing muscle strength in puberty and decreasing help from overgrowth and
remodeling (Fig. 13-11). Classic treatment for an adolescent with a femoral
fracture included traction for several weeks (until early callus formation—frac-
ture becomes “sticky”) followed by placement in a hip spica for many weeks to
allow further healing. This method remains popular in many settings but re-
quires lengthy hospitalizations with intensive maintenance and traction adjust-
ment, which is time consuming for the surgeon, nurses, and orthopedic techni-
cian staff.

Figure 13-10. Early post-spica x-ray. It is

often difficult to determine if the callus is
adequate to resume weight bearing.
Our guide to children 0-8 years regarding how to rehabilitate from a fracture
and casting is guided by observations in the animal kingdom.The dog on the
left required no instruction and rests comfortably after knee surgery.
The dog on the right had a femur fracture and did not have the benefit of
casting. She elected 3-legged walking for a month and then resumed her nor-
mal quadriped gait.
Cast design crutches and wise surgeon advice will allow most children to
heal equally well.

Figure 13-11. In older children and teen-

agers, shortening needs to be corrected as
overgrowth does not occur as frequently.
 Although traction techniques for femoral fracture treatment are a dying art 191
in many institutions, the method offers many treatment variations and should Treatment
be understood by all who treat femoral fractures. Although time consuming,
traction avoids the risks of anesthesia, surgical fixation, and the almost in-
evitable later implant removal.
With larger children, care in a spica cast becomes a burden to the family and
patient. In much of the developed world where both parents may be full-time
employees, keeping a child out of school for an extended period becomes unrea-
sonable (Fig. 13-12). However, in much of the world, families are extended,
with multiple family members to care for a child in a spica cast or traction. Also
in these circumstances, operating rooms, image intensifiers, fully trained sur-
geons, and medical equipment are less affordable; treatment choices must fit
the culture as well as the injury.

Flexible Nail Methods

The development of flexible intramedullary nail systems in North America
(Rush, Ender) and Europe in the last two decades has revolutionized the care of
children with fractures in this age group. The elastic titanium Nancy nail
method of Metazeau and Lascombes, with further development and populariza- The Flexible Nail Revolution
tion by Parsch, Slongo, and others, has become a widely accepted treatment (The Nancy Nail)
method for adolescents in most centers in the United States and Canada. Jean Paul Metazeau (Nancy, France)
The advantages of flexible nails over metal plates or formal intramedullary popularized a method called “em-
rods are considerable. Although easy to apply, metal plates on the femur are brochage centromedullaire elastique
very difficult to remove without incurring a subsequent femur fracture (too lit- stabile” in the early 1980s.
tle load sharing). Formal rod systems require a proximal entry site, which may This method, based on principles first
developed in Romania, evolved into the
risk damage to the growth center of the greater trochanter or, in a worst case current method known in North
scenario, avascular necrosis (AVN) of the femoral head. The distal entry site for America as “flexible nailing,” which has
most flexible nail system avoids these risks. wide application for treatment of chil-
Flexible intramedullary nailing can be accomplished with either stainless dren’s fractures.
steel or titanium implants. Largely, theoretical advantages have led some to ad- Lascombe, Parsch, Prevot, Ligier, Slango,
vocate one over the other. Stainless steel is stiffer in bending; yet titanium, Heinrich, Rang, and others helped to
make this a widely used method in
which is more elastic, may conform and contact a larger area of the medullary North America.
canal resulting in improved fixation. One real advantage of the latest titanium (Photo courtesy of Pierre Lascombe.)
implants is the superior tools for insertion (and removal).

A B
Figure 13-12. A) Modern American mother “always on the go” often with inadequate time or extended family support for time-consuming
treatment such as traction. B) Haitian families with a large extended family, all involved in the care of the child, may be more willing to accept
treatment methods that require lengthy hospitalization or prolonged attention at home. Photos provided courtesy of Michelle Marks (Left)
and Dennis R.Wenger (Right ).
192 TECHNIQUE TIPS:
Femoral Shaft Flexible Intermedullary Nailing

Distal entry site—2 “C” nails

Proximal entry site—“S” and “C” nails

1. Preoperative planning: the narrowest diameter of the
diaphyseal canal is measured. The width of each nail
should be 35%-40% of this diameter (example, if
canal diameter is "1 cm, use two 4 mm nails).
Larger diameter nails give better stability and de-
crease the risk of nonunion, but "80% canal fill
risks additional comminution.
2. For most fractures, an entry point 1.5-2 cm above
the distal femoral physis in the metaphyseal flare is
preferred. One nail should enter from the medial
side and one from the lateral side to stabilize varus-
valgus angulation. With distal entry sites, the two
nails can both be “C” shaped.
3. For distal fractures, consider a proximal entry point
on the lateral aspect of the femur and just below the
apophysis of the greater trochanter. The nails should
be pre-bent: one into a “C” shape and one into an
“S” shape so that one ends medially and one laterally
in the distal femur.
4. The widest separation of the two nails should be at
the level of the fracture. To get the nails into the
proximal portion, turn the nail into antiversion as it
approaches the femoral neck.
5. Back the nails out 1 cm, cut to leave 1.5-2 cm out of
the bone for easy removal, and then tamp back into
place.
Variation of technique described by Ligier, Metazeau, Prevot,
and Lascombe—see Suggested Readings.
 Another controversy regarding flexible nail usage relates to the site of inser- 193
tion—proximal versus distal. In either case C-shaped segments of the nails Treatment
should be placed with opposing orientation to provide balanced varus and val-
gus bending moments at the fracture site. Distal insertion medially and laterally
of 2 C-shaped rods makes this a straightforward task. Both nails should be sim-
ilar diameter and generally pre-bent to a similar degree. Proximal insertion can
be accomplished through a single lateral incision (at the level of the greater
trochanter). Contouring the nails requires more attention with one C shaped
and one S shaped. The two limbs of the S, however, are not of equal length—
the proximal limb should be a short sharp curve. The S-shaped rod requires
rotation through 180° as it is inserted to turn the lower limb of the S in the op-
posite orientation of the C. Proximal fixation is most stable if the starting hole
is in the lateral femoral cortex just below the flare of the greater trochanter. Fix-
ation of distal femoral fractures is best with the proximal insertion method,
whereas in most cases the simpler distal insertion method is used for middle
and proximal fracture locations.
Usually inserted from the distal end of the femur, the single most important
advantage of the flexible nail system is avoidance of the risk for femoral head
There are now many commercially
AVN. The disadvantages include need for a second surgery to remove the nails,
available titanium elastic nail sets with
risk of bursitis over the prominent nails, infection, and malunion (especially in easy to use insertion instrumentation.
larger children with enough weight and muscle force to bend the flexible nails).
Postoperatively, although some surgeons still prefer spica casting, if the fracture
is stable, a knee immobilizer and crutches can be used, allowing the patient to am-
bulate independently and return to school within a week. The learner will likely
use a spica more often until the flexible nailing technique has been mastered.

Age 14 Years And Older

Treatment in this age group still provides treatment choices. For extreme tradi-
tionalists or those working in an environment where surgical methods are not
affordable, traction methods followed by hip spica casting can still be used.
Tremendous attention is required to ensure angular control as well as mainte-
nance of equal limb lengths. Smaller children in this age group can still be
treated by flexible intramedullary nail systems, which are available in larger di-
ameters (4-4.5 mm).
As patients get larger, the risk for angulation or loss of fracture position in-
creases with flexible nail fixation (Fig. 13-13). For these reasons, older children
are commonly treated with formal intramedullary rod fixation. The early gener-
ations of intramedullary nails and those typically used in the adult population
have a piriformis fossa entry site, which has been shown to put the femoral head
at risk for AVN. This risk is greatest when the physes are still open with limited
blood flow across the open physis.

Trochanteric Entry Site Intramedullary Rods

Newer intramedullary rods are now available that have a curvature that allows
Figure 13-13. As patients get larger, the
introduction through the greater trochanter. With proper technique, the vascular
risk of angulation of loss of alignment with
supply to the femoral head that encircles the base of the femoral neck is com- flexible nails increases. Such cases are bet-
pletely avoided thus significantly reducing the risk of AVN. This method offers ter treated with a solid nail (trochanteric
an ideal solution for the older child; fracture stability is maximized allowing early entry).
weight bearing with no need for casting or prolonged bed rest. However, expense
becomes an issue because the newest and best systems are always more expensive.
There is a risk for nonunion if the fracture is fixed with a gap at the fracture site,
however, this can be overcome with dynamization of the nail if necessary.
194
Femoral Shaft
TECHNIQUE TIPS:
Interlocking Intramedullary Nails
Piriformis
Trochanteric fossa entry
entry
1. Preoperative planning: the narrowest portion of the
canal should be measured on the x-ray to determine
nail diameter—the canal should be filled with the
nail. Use the contralateral leg to determine length—
either a plain x-ray or fluoroscopy with a ruler will
ensure equal leg lengths. Note the alignment of the
uninjured leg to avoid fixing the fractured femur in
malrotation.
2. A fracture table with the leg adducted simplifies frac-
ture reduction, fluoroscopy, and nail insertion.
3. The tip of the trochanter is usually palpable even on
very large children (if not, c-arm can be used as a
guide), a guide pin can be inserted through the skin
and into the lateral side of the tip of the trochanter
prior to making any incision—this pin should never
slip medially into the piriformis fossa as this puts the
vascular supply to the femoral head at risk.
4. Using c-arm, the guide pin is inserted through the
trochanter and down the proximal shaft, guided by
AP and lateral image views.
5. Now a very small (1 cm) incision can be made around
the guide pin to allow reaming and nail insertion.
6. Oblique, spiral, and comminuted fractures should
have distal interlocking screws placed to maintain
length and alignment.

TECHNIQUE TIPS:
Submuscular Plating
1. Through a small proximal incision, a Cobb elevator
can be used to gently separate the periosteum from
the overlying muscle.
2. The plate is pre-countoured using the contralateral
femur as a template; it is then slid into place extra-
periosteally.
3. Proximal screws are inserted percutaneously.
195
Treatment
4. Several companies have developed instruments that
can be used through a hole in the plate to pull the
distal fragment to the plate.
5. Once the fracture is reduced, the remaining screws
are inserted.
Published courtesy of Enis M. Kanlic, MD, PhD, Texas Tech
University Health Science Center at El Paso.
196
Femoral Shaft
“The external fixator for
treatment of femoral
fractures in childhood still
has a place on the surgical
supply shelf. In our
institution it is now just
behind the flexible nail set”
Dale Blasier MD—May 2003 POSNA
trauma course, Jacksonville Florida
Figure 13-14. External fixation is com-
monly used for open fractures and unsta-
ble patients.
ALTERNATIVE TREATMENT METHODS
FOR ANY AGE CHILD WITH FEMUR
FRACTURE
Submuscular Plating
Minimally invasive techniques of plating the femur allow little soft tissue dis-
ruption, no stripping of the periosteum, and anatomic alignment by an indirect
method. This technique has been adapted from adult fracture management and
is being used in younger children with excellent results in several centers. A pre-
contoured plate can be inserted through a small incision proximal to the frac-
ture and slid along the lateral femoral cortex to span the fracture. Screws are
then inserted percutaneously using fluoroscopic guidance. This technique does
necessitate a second surgery to remove the plate, which can be more destructive
than its insertion if care is not taken to preserve the soft tissues. There is an in-
creased risk of late fracture through the screw holes following plate removal.
External Fixation
External fixation provides a quick method of stabilizing the fracture if the pa-
tient is unstable and is likely to need further procedures such as soft tissue cov-
erage. For example, traction and casting must be avoided when there is concern
about spine injury or intraabdominal or intrathoracic injury or if the patient
will be making frequent trips to the CT scanner or operating room. These are
excellent indications for an external fixator that will stabilize the fracture
quickly and not interfere with care of the child’s other injuries.
Airplane transportation is also much easier in an external fixator (as com-
pared to a hip spica cast). Thus femur fractures in the children of tourists at ski
areas (who must fly home after their holiday) are commonly treated with exter-
nal fixators. External fixator immobilization can be converted to standard in-
tramedullary fixation or spica casting at a later time. If the fracture is allowed to
heal completely with the external fixation in place, there is a continued risk of
infection while the pins are in place and significant risk of fracture through the
holes following removal of the fixator.
As with external fixators in other locations, half pins should be inserted per-
pendicular to the shaft and close to the fracture (Fig. 13-14). More pins increase
the initial stability but also increase the later fracture risk. The large soft tissue
envelope around the femur make infection, pain, and scarring from the pins
bigger issues than when used for other bones such as the tibia. For these rea-
sons, many surgeons avoid external fixation if the femur can be stabilized with a
different technique.
Open Fractures
Open fractures can be graded according to the Gustillo and Anderson classifica-
tion (Table 13-2); however, this classification has not
. been shown to be as valu-
able in pediatric fractures. Open fractures result from much higher energy
mechanisms that should caution the surgeon to look for other injuries. Open
fractures should be taken to the operating room within 12 hours for formal
débridement and irrigation, or sooner if there is neurovascular compromise.
These fractures should be stabilized early with intramedullary nails, plate, or ex-
ternal fixator. Unless there is minimal contamination and soft tissue injury,
open fractures should not be placed in a cast.
 Table 13-2 Gustilo and Anderson’s Open Fracture Classification 197
Acceptable Results
Type Soft Tissue Injury
I Clean wound !1 cm
II Laceration "1 cm (no extensive soft tissue damage)
III Massive soft tissue damage, high-energy trauma
IIIA Adequate soft tissue coverage
IIIB Contaminated wound, periosteal stripping
IIIC Arterial injury requiring revascularization

From Gustilo, J Trauma 24:742–6, 1984.

ACCEPTABLE RESULTS
Few issues remain so unsettled as to what angulation or length difference can be ac-
cepted following treatment of a femur fracture. The biologic phenomenon of over-
growth due to postfracture growth stimulation has led to a somewhat “laissez faire”
approach to maintaining adequate length during treatment in children. In young
children, this is often acceptable. In older children, the chance for significant stim-
ulation and correction of limb difference decreases and one may be left with a
limb-length difference. Similarly, internal fixation can on occasion stimulate over-
growth to make the limb too long, particularly if plate fixation is used. This may be
less common with the use of flexible intramedullary nails but still can occur.
Families seem more concerned about a limb that ends up being short than if
it is long. The biologic phenomenon of fracture stimulation and overgrowth
seems to carry less “blame,” although the effect on gait, spine asymmetry, etc., is
equal whether the limb is “too long” or “too short.”
Traditionally, orthopedic surgeons have been taught that patients could adapt to
a 1-inch limb difference without difficulty. Gross interviewed a group of runners en-
tered in a marathon race regarding whether or not they had lower limb symptoms
and then carefully measured them to determine who had a limb-length difference.
He found that runners with up to a 2-cm limb length difference did not notice it or
did not have symptoms. This is one of the few research papers focusing on this
topic; however, the research methodology used does not meet current standards.
We are unwilling to state with certainty the amount of final residual limb,
length difference that can be accepted following femoral fracture but believe
that 2 cm should be considered as an upper limit. Ideally, one should try to
o
achieve a final difference of 1 cm or less. Anyone who thinks that a 1 1/2 cm
limb-length difference is of no consequence should try to wear an insole or shoe
lift on one side for a single day. The alterations in stride and knee mechanics are
remarkable. Practical knowledge suggests that, as orthopedics becomes more so-
phisticated and patients become more likely to participate in athletics and vig-
orous activities throughout a very long life (our life expectancy is extending rap-
idly), standards of acceptance for limb-length difference will likely diminish.

Monitoring Limb-Length Difference

Finally, a good knowledge of plotting and following length difference and appli-
cation of contralateral epiphysiodesis to correct any unavoidable difference
Figure 13-15. A scanogram is commonly
(prior to growth plate closure) are essential to the orthopedic armamentarium used to determine leg-length discrepancy
(Fig. 13-15). There are several methods of predicting leg-length discrepancy at following femoral fractures. Serial studies
skeletal maturity (see Technique Tips—Calculating Leg-Length Discrepancy). may be needed to plan epiphysiodesis.
198 TECHNIQUE TIPS:
Femoral Shaft Calculating Leg-Length Discrepancy and
Timing Epiphysiodesis

The Green and Anderson growth chart can be

used to estimate the growth remaining in a normal
distal femur or proximal tibia following consecutive
skeletal age levels.
See Anderson, M, Green,WT. JBJS 45A:1-14, 1963.

-
an
or

The arithmetic method of predicting growth remaining in a

normal limb is the least accurate method but can be used for a
quick gross estimation of growth remaining in a busy clinic.

Mosley used the Green-Anderson data to develop an ele-

gant graphic method of predicting future growth in children
with a leg-length discrepency. This methods requires con-
secutive evaluations to predict the best time for epiphys-
iodesis.
See Mosley, CF. JBJS 59A(2):174-9, 1977.

Herzenberg and Paley’s multiplier method offers a more complex

calculation that can be used to appropriately time epiphysiodesis for
equalization of a leg-length discrepancy on the first visit. For a more
detailed description of how to use this method refer to Paley et al.
JBJS 82A(10):1432-46, 2000.

Figures reproduced courtesy of the Journal of Bone and Joint Surgery.

The Green-Anderson method provided the classic approach; the Mosley 199
straight-line graphic method utilizes the Green-Anderson data to allow an ele- Suggested Readings
gant graphic prediction. The Melbourne method allows a simple estimation of
growth remaining in the distal femoral and proximal tibial physis relying on ob-
servational data showing that the distal femoral physis grows 10 mm/year and
the proximal tibia approximately 6 mm/year until skeletal maturity (age 16
years in boys, 14 years in girls). Paley and Herzenberg have developed a multi-
plier method for determining predicted discrepancy with a single time point.
This requires a more complex calculation but has been shown to be quite accu-
rate for timing of epiphysiodesis to correct leg-length discrepancies.

Methods to Close the Physis

Once the timing of epiphysiodesis (technically a better term would be phys-
iodesis) has been determined, growth plate closure can be completed in one of
many ways. Phemister described removing a 1 % 1 % 1cm rectangle from both
the medial and lateral sides of the physis, turning the block 90°, and reinserting
it into its bed to permanently stop further growth of the physis (Fig. 13-16). A Figure 13-16. Phemister method of epi-
curet or drill can also be used to methodically disrupt the physis enough to pre- physiodesis, rotating a 1 % 1 % 1 cm block
vent further growth. Some surgeons advised closed, percutaneous image-guided 90˚.
methods to curet the physis; however, these methods require experience and pa-
tient volume. One can easily damage the joint cartilage of the distal femur with
percutaneous methods. Most of our staff prefer open methods (faster, more cer-
tain physeal ablation).
Staples can be used, but they require a second surgery for removal at the time
of leg-length equality; they are good to use in younger children if the surgeon
prefers only temporary growth arrest instead of the more permanent methods
described previously (Fig. 13-17).

SUMMARY
Femur fractures are one of the most common injuries that the pediatric ortho-
pedic surgeon encounters. With adequate understanding of the injury and its
possible sequelae including possible leg-length discrepancy and malalignment,
femoral shaft fracture treatment will allow predictable return to normal Figure 13-17. Epiphyseal stapling can be
anatomy and function. used; however, this method requires a sec-
ond surgery for staple removal at the time
of leg-length equality.

Suggested Readings
Beaty, J.H. Femoral shaft fractures in chil-
dren and adolescents. Journal of Ameri-
can Academy of orthopedic surgeons
3:207–217, 1995.
Blasier, R. D.; Aronson, J.; and Tursky, E. A.:
External fixation of pediatric femur frac-
tures. J Pediatr Orthop, 17(3): 342–6,
1997.
Czertak, D. J., and Hennrikus, W. L.:
The treatment of pediatric femur
fractures with early 90-90 spica casting. J
Pediatr Orthop, 19(2): 229–32, 1999.
Flynn, J. M.; Luedtke, L.; Ganley, T. J.; and
Pill, S. G.: Titanium elastic nails for pedi-
atric femur fractures: lessons from the
learning curve. Am J Orthop, 31(2):
71–4, 2002.
Flynn JM et al. Comparison of titanium elas-
tic nails with traction and a spica cast to
treat femoral fractures in children. JBJS
Am 2004 86:770–777.
Galpin, R. D.; Willis, R. B.; and Sabano, N.:
Intramedullary nailing of pediatric femoral
fractures. J Pediatr Orthop, 14(2): 184–9,
1994.
Gustilo, J. Trauma 24:742–6, 1984.
Hedequist, D.; Starr, A. J.; Wilson, P.; and
Walker, J.: Early versus delayed stabiliza-
tion of pediatric femur fractures: analysis
of 387 patients. J Orthop Trauma, 13(7):
490–3, 1999.
Heinrich, S. D.; Drvaric, D. M.; Darr, K.;
and MacEwen, G. D.: The operative sta-
bilization of pediatric diaphyseal femur
fractures with flexible intramedullary
nails: a prospective analysis. J Pediatr Or-
thop, 14(4): 501–7, 1994.
Large TM, Frick SL. Compartment syndrome
of the leg after treatment of a femoral frac-
ture with an early sitting spica cast. A re-
port of two cases. J Bone Joint Surg Am.
2003 Nov;85-A(11):2207–10.
Ligier J, Metaizeau J, Prevot J, Lascombes P.
Elastic intramedullary nailing of femoral
fractures in children. J Bone Joint Surg
(Br) 70:74–77, 1988.
Linhart, W. E., and Roposch, A.: Elastic sta-
ble intramedullary nailing for unstable
femoral fractures in children: preliminary
results of a new method. J Trauma, 47(2):
372–8, 1999.
Mazda, K.; Khairouni, A.; Pennecot, G. F.;
and Bensahel, H.: Closed flexible in-
tramedullary nailing of the femoral shaft
fractures in children. J Pediatr Orthop B,
6(3): 198–202, 1997.
Parsch, K: Modern trends in internal fixation
of femoral shaft fractures in children. A
critical review. J Pediatr Orthop B,
6:117–125, 1997
Ryan, J. R.: 90-90 skeletal femoral traction
for femoral shaft fractures in children. J
Trauma, 21(1): 46–8, 1981.
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Schwend, R. M.; Werth, C.; and Johnston,
A.: Femur shaft fractures in toddlers and
young children: rarely from child abuse. J
Pediatr Orthop, 20(4): 475–81, 2000.
Staheli, L. T., and Sheridan, G. W.: Early
spica cast management of femoral shaft
fractures in young children. A technique
utilizing bilateral fixed skin traction. Clin
Orthop, (126): 162–6, 1977.
Thomas, S. A.; Rosenfield, N. S.; Leventhal,
J. M.; and Markowitz, R. I.: Long-bone
fractures in young children: distinguish-
ing accidental injuries from child abuse.
Pediatrics, 88(3): 471–6, 1991.
Thometz, J. G., and Lamdan, R.: Os-
teonecrosis of the femoral head after in-
tramedullary nailing of a fracture of the
femoral shaft in an adolescent. A case re-
port. J Bone Joint Surg Am, 77(9):
1423–6, 1995.
Weiss A et al. Peroneal nerve palsy after early
cast application for femoral fractures in
children. J Pediatr Orthop. 1992 Jan;
12(1):25–8.
 14 Knee
Maya Pring m Dennis Wenger

• Assessment 202
• Radiographic Issues 203
• Knee Dislocation 203
• Patella Dislocation 205
• Distal Femur Fractures 207
• Proximal Tibia Fractures 209
• Meniscus and Ligament Injuries 211

INTRODUCTION
Acute hemarthrosis of the knee secondary to injury is very common. The knee
“Consistency is
is a complex hinge joint with minimal capacity for rotation, which is held to-
gether by ligaments and cushioned by circular cartilage wedges that are all easily
contrary to nature,
injured. With conditioning, good muscle tone, and good alignment, the knee contrary to life. The
can last a lifetime. Add a touch of obesity, poor conditioning, poor alignment,
(anteversion, valgus), or an unlucky twist in sports and one’s knee can quickly only completely
become a lifelong liability (Fig. 14-1).
Fractures about the knee in children are common and fortunately heal well if consistent people
the diagnosis and treatment are correct. At adolescence, the specter of cartilage-
ligament injury increases, making results less certain. are the dead”
Making a clinical diagnosis of an acutely swollen knee may be difficult on the
first exam when “everything hurts.” Acute patellar dislocation is common and the
—ALDOUS HUXLEY
femur and tibia each have a physis near the joint that can be injured. In the child’s
knee, the collateral ligaments are stronger than the growth plates; therefore, epi-
physeal separation is more common than acute ligamentous tear. The cruciate lig-
aments attach to the tibial spines and the anterior spine is often avulsed. The ph-
ysis of the tibial tubercle can be traumatically injured. Although fractures are
201
202
Knee
A For a child with a large hemarthrosis, aspiration will help symptomatically
B
Figure 14-1. There are many factors that
can lead to knee injuries. A) Note obesity
and genu valgum deformity. B) Athletic chil-
dren can have an unlucky twist. (Photo
courtesy of L. Manhiem.)
more common, the child’s knee is not immune to adult injuries, such as ligament
and meniscus tears, particularly in the adolescent and teenage years.
ASSESSING THE PATIENT
Acute post-traumatic hemarthrosis in childhood is thought to be predictive of
intra-articular pathology. Stanitski reported a series of 70 children who pre-
sented with acute knee trauma and hemarthrosis; all had arthroscopy. The ma-
jority were found to have intra-articular lesions (meniscus tear, ACL tear,
and/or osteochondral fracture). For a time, this created a frenzy of arthroscopic
evaluation for every child and adolescent with a swollen knee. There has been
much debate in the literature, both for and against early arthroscopy for diag-
nosis; a recent article by Wessel et al. states “in children, compulsory
arthroscopy for hemarthrosis after knee trauma is not justified because ligamen-
tous and meniscal damage is rare.”
In today’s cost conscious medical environment, it may be difficult to decide
which patients should have an extensive workup (including MRI and/or
arthroscopy) and which patients may do just as well with a more conservative se-
quence. We lean toward a more conservative approach, saving the big workup
for those who do not improve in a timely fashion. Of course, one can never get it
just right. Demanding parents, whose child is “on a national travel team,” or the
soccer player who competes at the junior olympic level may not tolerate a
thoughtful, conservative, “lets see how things go” approach. For highly competi-
tive athletes, the Stanitski approach (early MRI or scope for all) is likely correct.
On the other hand, high-level insurance and unlimited resources are clearly not
available for all. The befuddled surgeon then becomes a pawn of the system, or-
dering or performing expensive tests on a select few while providing much less
for others. We can provide no certain answer to this dilemma; however, it is
comforting to know that most children do well with immobilization. They rarely
get stiff, and waiting for a few weeks is unlikely to do damage to the joint.
and may help you determine if there is a fracture: fat in the aspirate suggests
bony injury.
There are several clinical tests that will guide you through a differential diag-
nosis (see Technique Tips); however, these are hard to use if the patient is acutely
injured and will not let you touch the knee—a thorough exam becomes more
pertinent once the patient and the hemarthrosis have settled down. The opposite
may be true if an athlete can be examined immediately (even on the field). Many
would agree that this can be the best time to assess for acute ligament injury (the
nerve endings may be stunned temporarily by the acute event).
First palpate each area of the knee separately to find areas of point tenderness
(femoral physis, tibial physis, tibial tubercle, dorsal aspect of patella medially
and laterally, lateral femoral condyle). Then palpate the joint lines; if possible,
perform a McMurray (twist) test, and test the cruciate ligaments with the tests
described later.
ASPIRATION OF ACUTE
HEMARTHROSIS—DOES IT HELP?
A tense, acute knee hemarthrosis in a child (knee full of blood) is easy to aspi-
rate, yet not commonly done. Opinions as to whether it should be done range
widely within the orthopedic community. Several guidelines can be provided. If
the effusion is tense and the patient in great pain, aspiration may help. A rather
firm wrap, plus icing, must follow or it will rapidly reaccumulate.
 On the other hand, if the effusion is less tense, the patient has tolerable pain, 203
and he/she hates needles, aspiration can be avoided. In theory, if one sees fat Knee Dislocation
droplets on the aspirated blood, intra-articular fracture is likely. We advise a
case-by-case, individualized approach to the question of aspiration.

RADIOGRAPHIC ISSUES Common

Abbreviations
Standard knee evaluation includes an AP and lateral view of the knee and a —Knee
Merchant x-ray of both knees (Fig. 14-2). Patellar position is nearly impossible
ACL anterior cruciate ligament
to assess without a comparison to the uninjured side. If the patient has acute
hemarthrosis, it may be very difficult to flex the knee enough for a patellar view. PCL posterior cruciate ligament
Oblique x-rays may help, especially if a physeal fracture is suspected. MCL medial collateral ligament
If plain x-rays are normal, you are stuck with the question “Do I move the LCL lateral collateral ligament
knee or immobilize it?” Some advocate stress x-rays to check for physeal open-
ing; however, this is painful and not very reproducible—we therefore rarely per-
form stress views. An MRI can answer many questions (physis, ligament,
menisci) but is usually not necessary at the time of injury. There are few knee
injuries not visible on plain films that will worsen with a short period (1-2
weeks) of immobilization. This gives the soft tissues a chance to heal, the “A tense, acute knee
hemarthrosis a chance to resorb, and the bone a chance to begin healing (if hemarthrosis in a child
there is a nondisplaced fracture) and, more importantly, allows better clinical
exam that will direct further studies. If there is concern for ACL, PCL, or (knee full of blood) is easy to
meniscal injury, an MRI is the standard for diagnosis. aspirate, yet not commonly
done”
KNEE DISLOCATION
This is a very rare injury in children because the physis will usually separate be-
fore a dislocation occurs, but when it does occur, knee dislocations have a very

Figure 14-2. The AP, lateral, and

Merchant views are a common first
step to clarify knee trauma. The
Merchant (patellar) view allows one
to assess patellar instability, lateral-
ization, and dislocation.
204 TECHNIQUE TIPS:
Knee Tests Used for Assessing the Injured Knee

Lachman Test Anterior Drawer Test Quadriceps Active Test

Knee flexed to 30°. Anterior transla- Knee flexed to 90°. Anterior transla- Knee flexed to 45°. Contraction of
tion of the tibia indicates ACL tear. tion of the tibia indicates ACL tear. quads will translate tibia anteriorly if
ACL is torn.

Pivot Shift Posterior Drawer Test McMurray Test

Flex knee while applying valgus stress Knee flexed to 90°. Posterior transla- With valgus stress on the knee and ex-
and internal rotation. If ACL and pos- tion of the tibia indicates PCL tear. ternal rotation of the tibia, flex and ex-
tero-lateral corner disrupted, tibia will tend the knee. A torn medial meniscus
sublux. will “pop.”

Fairbank Sign Varus Stress Valgus Stress

Lateral translation of the patella. Pa- Knee flexed to 10°. Opening of lateral Knee flexed to 10°. Opening of medial
tient aprehension indicates patellar in- joint space indicates LCL tear. joint space indicates MCL tear.
stability.
poor prognosis. Initially, as in adult injuries, the major concern is neurovascular 205
injury. An arteriogram should be considered and the patient should be moni- Patellar Dislocation
tored extremely carefully for compartment syndrome. To truly dislocate the
femoral-tibial joint, multiple ligaments must be torn. Reconstruction of the lig-
aments will be required by someone experienced with this type of surgery.
“Between 5% and 10% of
PATELLAR DISLOCATION acute dislocations are
This is a very common injury and is what lay people mean when they say, “my
complicated by an
knee dislocated.” The injury is very common in adolescents and teenagers but osteochondral fracture”
less common in early childhood. We see many cases in teenage girls who are
somewhat loose-jointed, who have upper range . genu valgum (often with in-
creased femoral anteversion), and who are trying sports (but are really not con-
ditioned for it).
Most patellar dislocations are reduced before the patient comes to the hospi- At Injury
tal, either spontaneously by himself or herself or by a buddy. Diagnosis is not al-
ways easy. The signs are hemarthrosis, tenderness along the medial border of the
patella, lateral position of the patella, and a positive Fairbanks sign (patient be- A
comes apprehensive when you try to push the patella laterally).
Osteocartilagenous Fragment
On x-ray, always look for a loose fragment, which can be knocked off the lat-
eral femoral condyle or pulled off the medial edge of the patella (significant for
avulsion of the medial patellofemoral ligament—Fig. 14-3). Between 5% and
10% of acute dislocations are complicated by an osteochondral fracture.

Treatment—First Dislocation B

There is much argument about the treatment of a first dislocation. Tradition- After Realignment
ally, they have been immobilized in extension for 3-4 weeks with physical ther- C
apy started early. Recent trends include acute surgical intervention, particularly
Figure 14-3. A) This 14-year-old boy had a left
if an acute patellofemoral ligament tear is evident on x-ray or MRI.
patella dislocation while playing soccer. B) Note
If there is no fracture, we typically try conservative management ideally in a the osteocartilaginous fragment off the patella.
cylinder cast (because children tend not to use a knee immobilizer effectively), C) This patient was treated with an Insall soft tis-
followed by physical therapy for range of motion and to strengthen the vastus sue realignment procedure and excision of the
medialis. osteocartilaginous fragments.
For patients with a fracture of the medial patella or lateral femoral condyle,
we advise acute arthrotomy plus ligament repair with excision or fixation of the
fracture and repair of the medial capsule and patellofemoral ligament (plus pos-
sible lateral release).

Reccurent Dislocations
Fifteen percent to 20% of all children will experience recurrent dislocations of
the patella (and many more will have patellar alignment problems after their
initial injury). This is typically the result of faulty anatomy, including an in-
creased quadriceps angle, increased genu valgum, increased femoral ante-
version, femoral condyle hypoplasia, a shallow femoral sulcus, atrophy of the
vastus medialis, lateral patellar tilt, and/or general joint laxity. An Install type
soft tissue realignment or semitendinosus tendon tenodesis to the patella is
often recommended for skeletally immature patients with recurrent patella dis-
location. Tibial tubercle transfer procedures (Hauser, Fulkerson) cannot be per-
formed prior to physeal closure because they will produce genu recurvatum
owing to growth arrest in the anterior/distal extension of the proximal tibial
physis.
Figure 14-4. This child has bilateral bipartite patellae, which can be a normal finding, but in this case the right was symptomatic and re-
quired excision.

PATELLA FRACTURES
The patella is an interesting sesamoid bone designed to improve the lever arm
of the quadriceps mechanism. The patella is initially cartilaginous, becoming
ossified at age 3-5 years. Some children develop a synchondrosis between em-
bryonic growth centers that have not fused, leading to confusing x-ray findings.
A bipartite patella may be mistaken for a fracture of the patella (Fig. 14-4). The
typical secondary, bipartite center is located superolaterally. If there is confu-
sion, x-rays of the opposite knee may shed light on the situation, although some
cases are unilateral. To add more confusion, it should be noted that, although a
“The patella is an bipartite patella is usually a normal variant (and not the cause of pain), in rare
interesting sesamoid bone cases a fracture may propagate through the synchondrosis causing motion at
this junction (and symptoms). In rare cases, the secondary center requires surgi-
designed to improve the cal treatment (excision, lateral release, or fusion to main body of patella).
lever arm of the quadriceps The lower pole of the patella can be avulsed during the course of running,
jumping, and kicking. These are often injuries of the take-off leg. Acute injuries
mechanism” result in displaced fracture (sleeve fractures in children), chronic repetitive in-
juries producing the Sinding-Larsen-Johansson lesion of the patella (a form of
repetitive stress injury like Osgood-Schlatter lesion of the tibial tubercle—Table
14-2).
The characteristic lower pole avulsion fracture in childhood was coined as a
“sleeve” fracture by Houghton and Ackroyd because a circumferential cartilagi-
nous “sleeve” is plucked off the lower pole with little or no bone (Fig. 14-5). Di-
agnosis can be difficult, as sometimes there is little or no bone noted in the sep-

At Injury After ORIF

Figure 14-5. A, B) This is classic patellar sleeve fracture with avulsion of the distal pole. C, D) Following open reduction and internal fixation
with AO tension band technique.

206
arated fragment. Contralateral films allow you to compare the position of the 207
patella [the patella will be more proximal (patella alta) on the injured site]. Distal Femur Fractures
Recognition is important, because some of the articular surface of the patella
is displaced with the fragment. Without treatment, an extensor lag will remain
with a possible pseudarthrosis. Open reduction, repair of the retinaculum, rigid At Injury After ORIF
internal fixation of the fragment, and cast immobilization for 4 weeks are re-
quired. If there is little bone present, it is a bit like sewing two rope ends to-
gether. If you are not confident of the repair (or you imagine effect of the
postanesthetic shakes), insert a temporary wire loop between the patella and the
tibial tubercle for protection.
Transverse fractures through the substance of the patella are uncommon, ex-
cept in older teenagers. When widely separated, they are best treated by the AO
technique (parallel Kirschner wires and a tension band) (Fig. 14-6); however,
many are not sufficiently displaced to require surgery and can be treated by as-
piration of a tense effusion (optional) and a cast. Occasionally, marked patellar
overgrowth can occur following patellar injury in infancy. Figure 14-6. Comminuted patellar frac-
tures are a result of a direct blow to the
knee. They can be fixed with the AO ten-
DISTAL FEMUR FRACTURES sion band technique.
As previously discussed, the physis is a point of weakness in the growing child.
The distal femoral physis may be disrupted in several ways as described by
Salter and Harris (see Chapter 2). Salter-Harris Type I fractures are often not
visible on x-ray but can be suspected by a careful exam (tenderness directly over
the physis). True Type I injuries are rarely displaced and are well treated in a
long leg cast for 4 weeks. In many cases, with localized physeal pain (and nor-
mal x-rays), you are not certain of the diagnosis. One could order an MRI,
which is an expensive and impractical route. We advise a long leg cast for 2
weeks and then cast removal with repeat x-rays. If callus is noted at that time,
the child is casted for two more weeks.
Salter-Harris II injuries of the distal femur (Fig. 14-7) are common and are
concerning because of their tendency to produce physeal closure. Riseborough
reported that 11 out of 25 patients with distal femoral Salter-Harris II injuries
experienced subsequent physeal closure and leg-length discrepancy !2.4 cm.
X-rays often demonstrate a large Thurston-Holland fragment; the fracture often

At Injury

After CRPP

1 Year Later

Figure 14-7. Salter-Harris II injuries require anatomic reduction and have a very high
risk of physeal arrest. This patient had closed reduction and percutaneous pinning of his
fracture. One year following injury, his physis still appeared to be growing appropriately.
208 At Injury
Knee

After ORIF

Figure 14-8. Salter-Harris III injuries re-

quire open reduction and internal fixation
for realignment of the joint surface.

reduces easily with varus or valgus force depending on the injury. Following
anatomic reduction, these fractures can be placed in a hip spica or long leg cast.
If the reduction is unstable, percutaneous pinning should be performed. A few
require open reduction secondary to entrapped soft tissues.
The issue of cast type following closed reduction merits discussion. A long
leg cast alone will not ensure maintenance of reduction in a rowdy teenage boy.
Bending the knee to 90˚ and adding a pelvic band provides more certain stabil-
ity. If K-wires are used, a long leg cast should be enough. Finally, the family
must know about the high risk for physeal closure and the patient, followed ac-
cordingly.
In Salter-Harris III injuries, the posterior part of a femoral condyle may be
displaced (Fig. 14-8). Like most Type III injuries (e.g., Tillaux), these fractures
tend to occur as the physis is closing, so the risk of deformity or leg-length dis-
crepency following this injury is less likely. The fragment must be replaced
without devascularizing it. Type III injuries are unusual and should be anatom-
ically reduced with a transepiphyseal screw. The fracture can be reduced and
fixed with a compression screw through a posterolateral or posteromedial ap-
proach.
Type IV injuries also have a high risk for going on to partial growth arrest
(Fig. 14-9). Like any Type IV injury, anatomic reduction is required both to
allow subsequent physeal growth and to prevent arthritis (by anatomic joint
surface reconstruction).

Figure 14-9. This 13-year-old boy was hit by a car and sustained a Salter-Harris IV injury
and underwent open reduction and internal fixation.
 There are also a variety of osteochondral fragments that can become intra- 209
articular. The most common is a piece sheared off the lateral femoral condyle Proximal Tibia Fractures
following patella dislocation.
Osteochondritis (OCD) lesions may be the result of trauma but are more
often idiopathic. OCD lesions are most commonly seen in the medial femoral
condyle and best visualized on the notch view x-ray or MRI (Fig. 14-10). These
should be treated to avoid the osteocartilaginous piece becomming a loose
body, which can damage the joint. We recommend extra-articular drilling if the
articular cartilage is still intact. If the articular cartilage is disrupted, the frag-
ment should be fixed or excised.

PROXIMAL TIBIA FRACTURES

Tibal Spine
Injuries that rupture the ACL of an adult typically avulse the anterior tibial
spine in a growing child (Table 14-1). The spine repairs by bone when reduced
and yields much better results than a complete tear of the cruciate ligament.
The majority of fractures are produced in road accidents, particularly falls from
bicycles. A child presenting with an acute swollen knee after falling from a bi-
cycle should be presumed to have a fracture of the tibial spine until proven
otherwise.
Some children are unaware that anything is seriously wrong until the follow-
ing day, when the painful hemarthrosis persists. The radiologic findings can be
subtle, and the damage is always greater than the x-ray shows. Wide radiolucent
wings of articular cartilage from the weight-bearing surface of the tibia are at-
tached to the small ossific fragment. Much more than the spine is lifted up and
the fragment is usually partially detached. The anterior part lifts; the posterior
part hinges. The femoral condyles can be used to ram the wings of articular car-
tilage back into position when the knee is extended in an attempt at closed re-
duction. When the fragment is completely detached, meniscus are interposed,
or the fragment is rotated, and open reduction is required.
Type I injuries are treated simply with casting with the knee in slight flexion
(10°) for 6-8 weeks. Type II injuries need to be reduced. This can sometimes be ac- Figure 14-10. OCD lesions are most
complished in a closed fashion by extending the knee, but if the meniscus blocks commonly seen in the medial femoral
condyle. If left untreated, this may result in
reduction, open reduction and fixation should follow (Fig. 14-11). a loose body and cause further damage to
Type III injuries almost uniformly require surgery. Be prepared for stiffness the articular surface.
following fixation of these injuries. We have had several patients that required

Table 14-1 Classification of Tibial Spine Injuries

Type I Type II Type III

Nondisplaced Lifted anterior with posterior hinge Complete separation of spine

 Avulsion Fracture Intraoperative Image Postoperative CT Scan

Figure 14-11. Tibial spine avulsion fractures can be fixed arthroscopically with suture fixation.

manipulation and lysis of adhesions following both arthroscopic and open fixa-
tion of tibial spine fractures. There is always a debate as to when to start moving
the patient postoperatively. Every extra day in a cast increases the risk of stiffness,
but suture fixation is often not strong enough to hold the fracture until it is
healed. Although ACL laxity is a concern, stiffness seems to be a bigger problem.
As in multiple children’s orthopedic conditions, you will have to pick your poi-
son (too short of immobilization " pseudarthrosis, too long " joint stiffness).
Reduction and fixation of the spine can be accomplished arthroscopically or
by an open approach. The knee is opened through a medial parapatellar inci-
sion. Two holes are drilled through the epiphysis, and the fragment is tied
down. Some have advocated screw fixation of the spine to allow better fixation
and earlier motion. The screws must be kept in the epiphysis to prevent injury
to the physis (Fig. 14-12).

Tibial Tubercle Fractures

Figure 14-12. Tibial spine fractures can
be fixed with epiphyseal screws. This pro-
vides more secure fixation and does not
injure the physis.
Because the patellar ligament inserts onto the tibial tubercle apophysis, repeti-
tive forceful contraction of the quadriceps (runners, jumpers) can pull this
apophysis apart. This can happen slowly or acutely. Chronic stress to the
apophysis leads to Osgood-Schlatter disease or inflammation of the tibial tuber-
cle; this condition often precedes acute fracture of the tubercle (Fig. 14-13).
Most proximal tibia fractures can be classified according to the Salter-Harris
classification system; however, several attempts have been made to better clas-
sify tibial tubercle fractures. Both Watson Jones and later Ogden described
three types of acute fracture (Table 14-2).

Table 14-2 Ogden Classification of Tibial Tubercle Fractures

Type I Type II Type III

Tubercle hinged Extends into physis Breaks into joint

210
 At Injury 211
Meniscus Tears and Ligament Injuries

Intra-Op

Figure 14-13. Chronic pull of the tibial tu-

bercle apophysis leads to a stress reaction
(Osgood-Schlatter disease) and in some in-
stances, leads to fracture.

Figure 14-14. Type III tibial tuberosity

fractures are best treated with ORIF to re-
store the joint surface.

Treatment of tibial tubercle fractures depends on the skeletal maturity of the

patient and whether or not the joint is involved (Fig. 14-14). If the child is
skeletally immature, it is important not to place screws across the physis to
avoid anterior physeal fusion and subsequent recurvatum deformity. In this
case, a tension band from the patella to the anterior tibia will allow healing
without disrupting growth (Fig. 14-15). Frequently, these injuries occur as the
physis is starting to close; in this case, screw fixation is acceptable. If the joint is
disrupted, anatomic reduction of the joint surface is mandatory to prevent later
arthritis.

MENISCUS TEARS AND LIGAMENT

INJURIES
Although seen less commonly in children than in adults, meniscus injuries are
relatively common in adolescents. Also, congenital discoid menisci tear easily
and are commonly seen in large children’s centers. Diagnosis of meniscal injury
is more difficult in children because they rarely complain of locking and weak-
ness and may not have a positive McMurray test on clinical exam. Most com-
monly, a meniscus tear presents with decreased range of motion, tenderness at
the joint line, and quadriceps atrophy.
Harvell et al. reported that the accuracy of clinical diagnosis improves with
Figure 14-15. In children with open phy-
age—it is difficult to get a good exam on a young child with a knee injury. MRI ses, a temporary tension band between the
or arthroscopy will provide the definitive diagnosis of a meniscal tear. In times patella and the tibia can be used to fix a
gone by, menisectomy was performed for children with a torn meniscus—this is tibial tubercle fracture.
212 now contraindicated if it is possible to repair or salvage the meniscus. The long-
Knee term outcome of patients with menisectomy is dismal, leading to early arthrosis
and need for knee replacement. There are now many arthroscopic techniques
for repairing torn menisci that properly trained orthopedic surgeons can per-
form.
Normal Meniscus The discoid meniscus results from a congenital anomaly that predisposes the
cartilage to early tearing and degeneration (Fig. 14-16). The lateral meniscus is
most commonly affected, but discoid medial menisci have been reported. A
prominent clicking or snapping with knee motion is almost diagnostic of an
unstable discoid lateral meniscus in young children. Older children and adoles-
cents are more likely to present with symptoms of a torn meniscus—effusion,
joint line tenderness, and quad atrophy. Asymptomatic discoid menisci do not
require treatment; however, when these abnormal menisci become torn and
symptomatic, they are most commonly treated with arthroscopic saucerization
with preservation of enough meniscus to maintain some biomechanical func-
tion.

Ligaments
Ligamentous injuries may be the silent partners of femoral and tibial fractures.
A Always look for a knee effusion if there is a nearby long bone fracture, because
the unstable knee may be more memorable than the fracture.
Torn Discoid Meniscus

B along the medial or lateral collateral ligament, which crosses the joint. Stress
Torn Discoid Meniscus
At Surgery
C matic. Grade III injuries may still be tender and have varus or valgus instability.
Figure 14-16. A) MRI of normal menis-
cus. B) Note the torn lateral discoid menis-
cus. C) Torn discoid meniscus at time of
arthroscopy.
Collateral Ligaments
During the ski season, many children younger than the age of 10 arrive with
pain, swelling, and tenderness about the knee. Always consider a physeal injury
before a ligamentous injury in the growing child, but don’t discard the possibil-
ity of torn collateral ligaments. Physeal injuries present with swelling and ten-
derness circumferentially at the level of the physis and usually no tenderness at
the joint line. Collateral ligament injuries present with very localized tenderness
x-rays or an MRI can differentiate these injuries; however, the treatment is sim-
ilar, so these tests are usually not necessary.
In equivocal cases, it is best to immobilize the knee in a long leg or cylinder
cast for 2-3 weeks. This will give adequate time for most soft tissue injuries to
heal and prevent displacement if there is a physeal fracture. Follow-up x-rays
will then show callus if a fracture was indeed present. If there is no evidence of
fracture at 3 week follow-up, the knee stability is tested. Grade I and II liga-
mentous injuries will have healed completely and the patient will be asympto-
These patients should be placed in a hinged knee brace to protect the ligament
while it continues to heal for an additional 3-6 weeks. It is very rare that iso-
lated collateral ligament injuries do not heal completely in the child with con-
servative management. Collateral ligament injuries in combination with ACL
and/or meniscus tears may require a more aggressive approach, which is dis-
cussed thoroughly in sports medicine texts.

Anterior Cruciate Ligament (ACL)

In the past, it was said that children’s ligaments are stronger than the bone, so
they do not get ligament injuries. This has been proven untrue by today’s ag-
gressive athletic children. Bony avulsions of the ligaments are still more com-
mon (tibial spine, distal femoral and proximal tibial physeal injuries); however,
we now see more than 50 intra-substance ACL tears a year in our institution. 213
These ligament tears occur during deceleration—often when landing from a Meniscus Tears and Ligament Injuries
jump. A loud pop is often heard followed by immediate hemarthrosis. The pa-
tient presents with an acutely swollen knee and instability on exam—the Lach-
man test is the most sensitive finding in a patient with an acute ACL tear. There
is often an associated meniscus tear or osteochondral injury, which is indicated DEFINITIONS
by joint line tenderness. An MRI will clarify the diagnosis (Fig. 14-17). Strain—a stretching injury of
Initial management of an ACL injury includes immobilization, ice, and
a muscle or its tendinous
crutch use. Once the acute swelling has subsided, range of motion exercises can
be begun in a brace that prevents anterior translation of the tibia. Whether one
attachment to bone
opts for reconstruction or conservative management, therapy is important to re- Sprain—an injury limited to a
gain knee motion. The surgical options are limited in patients with open physes, ligament
and many surgeons prefer to wait until close to skeletal maturity to perform the Grade I—a tear of a mini-
standard bone-tendon-bone reconstruction that is utilized in adults. The bone mum number of fibers of
plugs for this type of reconstruction cross and risk closing the distal femoral and the ligament with localized
proximal tibial physes, so it is not recommended when the physes are open. tenderness but no instability
Children that are active in sports are often unwilling to wait and wear a brace Grade II—a disruption of
with the increased risk of meniscus tear. We see children as young as 10 with more fibers with more
ACL tears and it is next to impossible to convince them to wait until their teen generalized tenderness and
years for surgery and a stable knee. Therefore, many techniques have been de- mild laxity
veloped to protect the physes and reconstruct the ACL in skeletally immature Grade III—a complete dis-
patients. We refer you to textbooks directed to sports medicine for children for
ruption of the ligament with
in depth discussions of these techniques.
resultant instability
Posterior Cruciate Ligament (PCL)
PCL injuries are very rare in children. They usually occur from a direct blow to
the anterior tibia when the knee is flexed. In isolated PCL tears, there is often
no hemarthrosis as the PCL is extra-synovial. A posterior sag is noted on clinical
exam, and a quadriceps active test will show anterior translation of the tibia
when the quadriceps are contracted (knee held in 70° of flexion). As in ACL in-
juries, bony avulsion is more common and, if significantly displaced, can be re-
duced and fixed (Fig. 14-18). If there is a true intra-substance tear noted on
MRI or diagnostic arthroscopy, conservative management with therapy and
bracing is usually adequate.

At Injury

Normal A

ACL PCL Torn

ACL PCL

B
Figure 14-18. A) In children, the PCL is
more commonly avulsed with a bony frag-
ment than a true intra-substance tear. B)
Figure 14-17. A) MRI of normal cruciate ligaments. B) Torn ACL with anterior subluxation This can be fixed with open reduction and
of the tibia. screw fixation.
Suggested Readings
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arthroscopic cannulated screw fixation.
Arthroscopy. 1995 Jun;11(3):328-31.
Flynn JM, Skaggs DL, Sponseller PD, Gan-
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management of pediatric fractures of the
lower extremity.Instr Course Lect. 2003;
52:647-59.
Harvell JC Jr, Fu FH, Stanitski CL. Diagnos-
tic arthroscopy of the knee in children
and adolescents.Orthopedics. 1989 Dec;
12(12):1555-60.
Houghton GR, Ackroyd CE: Sleeve fractures
of the patella in children. J Bone Joint
Surg 61B:165, 1979
Kocher MS, DiCanzio J, Zurakowski D,
Micheli LJ. Diagnostic performance of
clinical examination and selective mag-
netic resonance imaging in the evaluation
of intra-articular knee disorders in chil-
dren and adolescents. Am J Sports Med.
2001 May-Jun;29(3):292-6.
Kocher MS, Saxon HS, Hovis WD,
Hawkins RJ. Management and complica-
tions of anterior cruciate ligament in-
juries in skeletally immature patients: sur-
214
vey of the Herodicus Society and The
ACL Study Group. J Pediatr Orthop.
2002 Jul-Aug;22(4):452-7.
Matelic TM, Aronsson DD, Boyd DW Jr,
LaMont RL. Acute hemarthrosis of the
knee in children. Am J Sports Med. 1995
Nov-Dec;23(6):668-71.
Miller, MD, Howard, RF, KD Plancher. Sur-
gical Atlas of Sports Medicine. W.B.
Saunders Company; March 7, 2003.
Molander ML, Wallin G, Wikstad I: Frac-
ture of the intercondylar eminence of the
tibia. J Bone Joint Surg 63B89, 1981.
Myers MH, McKeever FM: Fracture of the
intercondylar eminence of the tibia. J
Bone Joint Surg 41A: 209, 1959.
Ogden JA, Tross RB, Murphy MJ: Fractures
of the tibial tuberosity in adolescents. J
Bone Joint Surg 62A:205, 1980.
Riseborough EJ, Barrett IR, Shapiro F.
Growth disturbances following distal
femoral physeal fracture-separations. J
Bone Joint Surg Am. 1983 Sep;65(7):
885-93
Schenck, RC. Athletic Training and Sports
Medicine, 3rd ed. AAOS, 2000.
Stanitski CL, Harvell JC, Fu F. Observations
on acute knee hemarthrosis in children
and adolescents. J Pediatr Orthop. 1993
Jul-Aug;13(4):506-10.
Thompson JD, Stricker SJ, Williams MM.
Fractures of the distal femoral epiphyseal
plate. J Pediatr Orthop. 1995 July-
Aug;15(4):474-8.
Vocke AK, Vocke AR. Cartilaginous avulsion
fracture of the tibial spine.Orthopedics.
2002 Nov;25(11):1293-4.
Wessel LM, Scholz S, Rusch M, Kopke
J, Loff S, Duchene W, Waag KL.
Hemarthrosis after trauma to the pedi-
atric knee joint: what is the value of mag-
netic resonance imaging in the diagnostic
algorithm? J Pediatr Orthop. 2001 May-
Jun;21(3):338-42.
Wiley JJ, Baxter MP. Tibial spine fractures in
children. Clin Orthop. 1990 Jun;(255):
54-60.
Willis R, Blokker C, Stoll T. Long term fol-
low-up of anterior tibial eminence frac-
tures. J Pediatr Orthop. 13:361-364,
1993.
 15Tibia
François Lalonde m Dennis Wenger

• Proximal Growth Plate Injuries 215

• Proximal Metaphyseal Fractures 217
• Diaphyseal Fractures 219
• Common Variations 222
• Distal Metaphyseal Fractures 225

INTRODUCTION
Tibial fractures heal so much more readily in children than in adults that they
“We see what we
should be a joy to treat. The majority of children have a cast applied and only
require a pair of crutches, a cast shoe, and a note for school outlining their lim-
know”
itations. —GOETHE
Most tibial fractures in children are stable and the child can soon be weight
bearing in an above knee (long leg) cast. However, there is more variation to
these fractures than is generally realized. If foresight is to be used to prevent
problems in treatment, the characteristics of the fracture should be well under-
stood. In this chapter, we will present tibial fractures and discuss common vari-
ations according to their anatomic location.

PROXIMAL GROWTH PLATE INJURIES

Growth plate injuries are more common in the distal femur than in the proxi-
mal tibia, because of the surrounding anatomy. The medial collateral ligament
of the knee is attached to the tibial metaphysis and the femoral epiphysis, pro-
tecting the tibial physis from valgus injuries. Laterally, the upper end of the
fibula acts as a buttress. In the posteromedial corner, the semimembranosus
muscle inserts distal to the physis, and anteriorly, the tubercle projects from the
epiphysis over the metaphysis.

215
216 Fortunately, proximal tibial physeal fractures are rare because injury at this
Tibia level is often associated with vascular problems owing to the proximity of the
. popliteal trifurcation into the posterior tibial, anterior tibial, and peroneal arter-
ies. Complete avulsions of the tibial tubercle are considered a specific subgroup
of this fracture and are discussed separately in the knee chapter.
“Growth plate injuries are The mechanism of injury in proximal tibial physeal injuries is either direct or
more common in the distal indirect. A direct injury can result from a child’s leg being run over by a vehicle
or when it is caught between bumpers of two automobiles. Most injuries are the
femur than in the proximal result of an indirect force such as forced abduction and hyperextension of the
tibia, because of the lower leg against a fixed knee. Most proximal tibial physeal injuries are Salter-
surrounding anatomy” Harris I and II fractures. The frequency of Salter-Harris III fractures varies ac-
cording to whether displaced avulsion fractures of the tibial tubercle are in-
cluded.
Up to 50% of type I separations of the proximal tibia are nondisplaced with
a tense hemarthrosis usually noted on physical examination. In this situation,
stress radiographs can be performed and may reveal widening on the medial or
posterior aspect (rarely actually done—very painful for child). For Salter-Harris
III and IV fractures, a CT scan is usually recommended to clarify the complex-
ity and thus guide.
Nondisplaced fractures can be treated in a long leg cast with the knee flexed
approximately 15° so that the child can walk comfortably. The cast is univalved
to allow for swelling, and depending on the clinical exam, consideration should
be given to admit the patient overnight to monitor for swelling and/or a com-
partment syndrome. At 1 week, plain x-rays are repeated to ensure there has
been no displacement of the fracture in the cast. The cast is removed 4 to 8
weeks after injury depending on the age of the patient.

“Displaced Salter-Harris II
fractures, like proximal
metaphyseal fractures, have
a high risk for associated
vascular injury”
Displaced Fractures
Displaced Salter-Harris II fractures, like proximal metaphyseal fractures, have a
high risk for associated vascular injury. Thus when a displaced fracture occurs,
assume a vascular injury and potential for a compartment syndrome. The pre-
cautions noted in the next segment on proximal metaphyseal fractures must be
taken to avoid morbidity.
Displaced Salter-Harris I and II fractures require closed manipulation prefer-
ably under general anesthesia. Unless the fracture is very stable, percutaneous
crossed Kirschner wires are generally used to secure the reduction. The pins are
removed in clinic 3 to 4 weeks after surgery through a window in the cast. Pins
left in more than 4 weeks after surgery may increase the risk for infection.

Stress X-ray in Children’s Fractures

In the past, stress radiographs were emphasized in the acute setting
as part of the routine workup of certain musculoskeletal injuries
such as a Salter-Harris I physeal fracture to confirm the diagnosis. If
not done under local anesthesia or intravenous sedation, stress ra-
diographs caused significant patient discomfort.
Today, stress radiographs are rarely performed. The information
obtained from the clinical exam and routine x-rays are usually suffi-
cient to make an accurate diagnosis. Often, the information gath-
ered from stress radiographs does not change the management of
the injury thus justifing the expense and potential discomfort to the
child.
 Inability to achieve an adequate closed reduction is often due to soft tissue 217
interposition, most likely perisoteum. In this circumstance, open reduction and Proximal Metaphyseal Fractures
internal fixation are indicated.
Salter-Harris III and IV fractures with associated step deformity or displace-
ment of more than 2 mm require open reduction and internal fixation, using At Inury After Reduction
screws or wires (Fig. 15-1). If screws are used, care is taken to avoid crossing the
physis unless the child is at an age that closure is acceptable (Fig. 15-2). With
fractures that extend into this joint or severely disrupt the physis, the patient is
kept non-weight bearing for the first 4 to 6 weeks.
Patients with proximal tibial physis fractures are followed for 2 years to
watch for signs of angular deformity, shortening (physeal closure), or persistent
instability (ligamentous injury).

PROXIMAL METAPHYSEAL FRACTURES

Masquerading as innocent little cracks with no particular reputation for evil, Figure 15-1. Salter-Harris IV proximal
proximal metaphyseal fractures can lead to serious problems. Two distinct types tibia fracture treated operatively and fixed
of fracture occur in this region, each with the distinct potential for an almost with temporary K-wires. If screws are used
predictable complication. for fixation, take care not to cross the
physis.

Arterial Hazard Fracture

At Injury
The anterior tibial artery passes over the proximal edge of the interosseous
membrane into the anterior compartment and is closely applied to the tibia.

The Hazardous Intersection—Proximal Tibia and Fibula

Nowhere in the body does anatomic configuration provide greater hazard for
the pediatric orthopedist. The intersection of two physes (that can be dis-
rupted), three vessels, and associated nerves (peroneal, tibial) create this danger.

After Surgery

Figure 15-2. This type II proximal tibia

fracture has a high risk for arterial injury.
The patient was near maturity; therefore a
fixation method that ensures closure was
used. K-wire fixation (and tension band
wire) can be used in younger children.
218
Tibia
At Injury 2 Years Later
A B
C 2 Years Later
Figure 15-3. Progressive deformity fol-
lowing a proximal tibia fracture. A) At in-
jury. B) Clinical photo 2 years later. C)
Standing x-ray 2 years later.
Figure 15-4. Five-year-old boy with a
proximal tibial metaphyseal fracture—
method for reduction illustrated. A) At in-
jury. B) Under anesthesia—further valgus
added to complete fracture. C) Now varus
applied—fracture is fully reduced. D) In
cast with full reduction.
Because of this fixed position, the artery may be compressed, stretched, or torn.
If it is stretched, the posterior tibial artery may also be occluded in a displaced
type II fracture or in a proximal metaphyseal fracture.
The initial sign of vascular damage may be a cold, pale, pulseless leg that in
about an hour becomes anesthetic and paralyzed, but often the findings are
more subtle and appear slowly. Muscle ischemia alone is less dramatic; a warm
skin has misled many.
With a proximal fibular fracture, the temptation to blame calf and foot neu-
rologic signs of ischemia on local lateral popliteal nerve damage should be resis-
ted. Arterial compromise and/or compartment syndrome must be suspected.
Reduction is urgent because correction of the displacement and angulation may
restore the circulation. If not, the vessels must be explored because prolonged
ischemia increases the risk for compartment syndrome. Ideally, a vascular sur-
geon and an orthopedic surgeon would collaborate. An angiogram may be help-
ful but should not overly delay intervention. If an arterial repair is performed or
compartment syndrome is diagnosed, four compartment fasciotomies should
be performed with internal fixation of the fracture to protect the soft tissues (in-
cluding the vascular repair) from further trauma.
Valgus Greenstick Fracture
In children between ages of 3 to 10 years, metaphyseal greenstick fractures have
attracted much interest. The cortex opens slightly on the medial side of the tibia
with the lateral cortex intact. The x-ray angulation is very unimpressive, and
most of these fractures are accepted as nondisplaced and are casted in situ fol-
lowing the adage that children’s fractures, particularly in younger children, can
be expected to remodel and thus don’t require exact angular correction.
When the cast is removed, the limb may initially appear in acceptable align-
ment, but subsequent progressive valgus comes as an unpleasant surprise (Fig.
15-3). This is due to the additive effect of the valgus produced by the fracture to
the often exaggerated valgus already present in this age group as well as subse-
quent asymmetric physeal stimulation due to the asymmetric (incomplete) frac-
ture. Although the valgus attitude may improve over time, it usually does not
correct completely and may require subsequent surgery (physeal stapling, rarely
osteotomy).
If one takes the trouble to look at the leg itself initially in the fully extended
position, comparing it to the opposite limb, the deformity is apparent. Unfortu-
nately, children hold the injured leg flexed, and in the flexed position the defor-
mity is less evident. Proximal tibial metaphyseal greenstick fractures are often
best corrected under anesthesia. The reduction can sometimes be improved by
first increasing the valgus (to complete the fracture) followed by a varus moment
(Fig. 15-4). The leg should be immobilized in extension with varus molding.
At Injury In OR In OR In Cast
Why Progressive Valgus? 219
Diaphyseal Fractures
Taylor drew attention to this injury and suggested that valgus was due to over-
growth of the tibia because of fracture hyperemia, whereas the intact fibula
acted as a tether. Overgrowth plays a part, but it has been our experience that if
the fracture is fully reduced, significant progressive valgus in unlikely. On occa- “When the cast is removed
sion, the medial gap cannot be reduced by closed manipulation because of soft the limb may initially
tissue interposition. Both the lower part of the pes anserinus and the thick pe-
riosteum avulsed from the lower fragment can be entrapped (Weber). In this in- appear in acceptable
stance, open reduction is needed to ensure an anatomic reduction. Once open alignment but subsequent
reduction is performed, the fracture is usually pinned to maintain reduction.
Aronson found that dividing the periosteum around the medial half of the
progressive valgus comes as
proximal tibia produced valgus deformity. This may be due to mechanical re- an unpleasant surprise”
lease of the restraint the periosteum imposes on the growth plate. Likely the
mechanism is multifactorial.
An established valgus deformity can be treated either with medial proximal ( vacsa )
tibia physeal stapling (at age 10-14 years, if the physis remains open) or with Cozen
deformity
corrective osteotomy. If a corrective tibia osteotomy is performed, an osteotomy

÷
do
an
of the fibula should also be done with anterior compartment fasciotomy plus
placement of a drain to minimize the risk of a compartment syndrome. Amaz- Do Not
ingly, recurrence of valgus deformity has been reported despite corrective os-
teotomy of both the tibia and fibula.
botany
DIAPHYSEAL FRACTURES
Diaphyseal (midshaft) fractures are common; however, a distinction should be
made between low- and high-energy trauma to predict the extent of soft tissue
injury. In the majority of cases, the fibula is intact. Often these fractures are sta-
ble and minimally displaced because of the more resilient periosteum in chil-
dren (in the adult, bone is stronger than periosteum, therefore the periosteum is
almost always torn when the bone is fractured).
In a child, the recoil of the intact periosteum holds the fracture in good posi-
tion. Displacement is much more common when both bones are fractured than
when the fibula is intact.

Cast Immobilization A

Low-energy, nondisplaced fractures are immobilized in a long leg cast applied in

two segments with the child’s leg hanging over the side of the bed (Fig 15-5).
The leg-calf segment should be applied with the limb in a vertical position to
ensure the best possible reduction. Casting with the patient supine may lead to
posterior angulation (gravity effect). In the “two-segment” application method,
good padding is required at the juncture (felt is ideal). The knee is then ex-
tended with the remainder of the cast applied.
The knee is flexed 10°-15° and the ankle casted in neutral flexion, if possible,
to allow for early weight bearing in stable fractures. It is important to mold the
cast at the fracture site and also at the arch and over the Achilles tendon to min-
imize loosening of the cast, avoid fracture displacement, and prevent heel pres-
sure sores.
B
If you wish to prevent walking on an unstable fracture, consider flexing the
knee beyond 80°. Note that most energetic children will still walk on the cast Figure 15-5. A) Casting the patient
with less flexion (!45°). There are only two rational choices (15° knee flex- supine may lead to posterior angulation
(gravity effect). B) Casting the patient with
ion—walking OK and 80° flexion—can’t walk). Check x-rays are performed
the limb hanging over the edge of the table
after casting. makes anatomic reduction more likely.
 At Injury 1 Year Post Injury
1 Year Post Injury

1 Year Post Injury

L R
L R
R L
Figure 15-6. This boy had flatfoot and a tibial fracture (distal).The valgus was accepted and 1 year later he had severe ankle valgus. He re-
quired an osteotomy. When considering what degree of malalignment to accept, one must consider associated factors (especially knee and
ankle valgus).

Fractures Requiring Reduction

Simple fractures may be reduced in the ER; however, many (and perhaps most)
significantly displaced tibia fractures are better managed in the peaceful OR set-
ting with ideal analgesia (general anesthesia) and a regular image intensifier.
What is an acceptable position? Rotation should be accurate because the knee
and ankle are hinge joints and residual will be noted by the patient. The goal is
to obtain at least 50% apposition of the tibia and alignment within 5° to 10° of
normal in all planes.
Decisions regarding who requires reduction can be difficult. The patient in
Figure 15-6 had a 10°-15° valgus angle at his fracture site, which was accepted.
Because he also had flatfoot, the combination led to severe ankle symptoms. He
required an osteotomy.
Loss of The cast is univalved to allow for swelling (bivalved in severe fractures). Most
Reduction After Wedging significant tibial fractures are admitted overnight to monitor for swelling and
signs of compartment syndrome. The leg should be elevated for 3 to 4 days.

A B
Figure 15-7. A) This patient was treated
operatively including cross K-wire stabi-
lization, the fracture began to drift into val-
gus in the cast. B) Correction of alignment
after careful cast wedging. This is an un-
usual type of cast wedging.
220
Monitoring Reduction
Fracture alignment must be monitored closely during the first 3 weeks after re-
duction. Occasionally, a full cast change under general anesthesia is required 2
to 3 weeks after injury to realign the fracture.
Alternatively, corrections can be made by wedging the cast in the clinic dur-
ing the first 2 to 3 weeks, although this must be done with skill as the wedging
can produce complications (skin or muscle necrosis) (Fig 15-7). The cast can be
wedged in one of three ways: a closing wedge, an opening wedge, or a combina-
tion. We most commonly perform an opening wedge correction at about 2
weeks post fracture when callus has begun to form (this initial stickiness mini-
mizes the chance for recurrence of angulation).
First, a transverse cut is made opposite the apex of the fracture (perpendicu-
lar to the long axis of the tibia). A small segment of the cast is left intact directly
over the apex of the angulated tibia utilizing two longitudinal stress relief saw
cuts. A cast spreader is placed into the cast opposite the apex of the bone, and
the cast is opened. A plastic block of appropriate size (usually 1 to 2 cm) is
placed into the opened segment and the cast is initially wrapped with tape (for
x-ray alignment check) and then overwrapped with casting material.
 The parents should be made aware of the potential for skin necrosis or com- 221
partment syndrome after wedging of casts. Prolonged, intense discomfort after Diaphyseal Fractures
wedging of the cast is often an indicator of problems. In this case, the wedge
should be removed and a new cast applied under general anesthesia.
In the presence of a stable, transverse fracture pattern, the patient is allowed
to start weight bearing with the help of a cast shoe once the cast is overwrapped
(univalve closed 7 to 10 days post fracture). Otherwise, weight bearing is de-
layed for about 3 weeks until early callus is present with cast change seldom
needed.
The cast is usually removed after 6 to 8 weeks. In infants, the bone unites in
K-wire After
3 weeks, whereas in some teenagers it will take 10 to 12 weeks or longer. In
At Injury Stabilization Healing
such cases, after 6 to 8 weeks, the patient is transitioned into a patellar-tendon-
bearing cast, short leg (below knee) cast, or an “off the shelf ” plastic cast brace.
When the cast is removed, some children will start to walk unaided immedi-
ately, but others need crutches for a week or two. Allow the child to decide
when to begin full weight bearing. A limp owing to calf wasting will persist for
several months after the cast is removed. Warn the parents about this to save
many anxious phone calls.

Operative Treatment
Unstable fractures of the tibia and fibula may require operative reduction and
stabilization, especially in older adolescents. Methods of fixation include percu-
taneous K-wires, external fixation, plates plus screws, flexible nails, and fixed in-
tramedullary nails. Indications for operative treatment include comminuted
fractures, irreducible fractures, fractures that cannot be maintained in a reduced Figure 15-8. Radiographs of young pedi-
position, fractures associated with compartment syndrome, open fractures, atric patient treated with a grade I open
multiple system injuries, and the so-called floating knee (fracture of both the tibial fracture. After débridement, the frac-
tibia and femur in the same limb). ture was stabilized with K-wires to ensure
maintenance of reduction.

Crossed K-wires
At Injury After Reduction
In patients younger than 6 years with open or unstable fractures, we favor
crossed percutaneous K-wire fixation followed by immobilization in a long leg
cast (Fig. 15-8). The K-wires are usually left outside the skin with felt around
and over the pin to protect the skin and prevent movement of the pin inside the
cast. The pins are removed through a window in the cast no later than 3 to 4
weeks after surgery. Pins left in longer than this may increase the chance of in-
fection.

Flexible Nails
In patients older than age 6 years, flexible intramedullary nails are the current
preferred method for stabilization of fractures requiring operative intervention
(Fig 15-9). The nails are inserted from the proximal metaphysis of the tibia
below the physis. Two C-shape nails are typically inserted; one from the antero-
medial aspect and the other from the anterolateral aspect of the metaphysis. An
alternative is to insert one C-shape and one S-shape nail both from the anter-
medial aspect of the metaphysis. If the fracture cannot be reduced by closed Figure 15-9. In patients older than 6
manipulation, the fracture site is exposed through a small incision to facilitate years, flexible intramedullary nails are the
passage of the nails. The nails vary in diameter between 2 and 4 mm. current preferred method for stabilization.
222
Tibia
“In patients younger than 6
years with open or unstable
fractures, we favor crossed
percutaneous K-wire fixation
followed by immobilization
in a long leg cast”
At Injury
Figure 15-10. In adolescents with closed physes, rigid in-
terlocking nails provide excellent stability.
In the older adolescent with open physes and wider intramedullary diameter,
it may be necessary to stack the nails by using two C-shape nails inserted an-
teromedially and two C-shape nails inserted anterolaterally to provide sufficient
fracture stability. A supplemental long leg cast is usually applied initially to help
maintain aligment until there is sufficient callus present.
Rigid Intramedullary Nails
In patients with closed physes, rigid, interlocking nails provide excellent stabil-
ity and may alleviate the need for postoperative immobilization (Fig 15-10).
COMMON VARIATIONS
The Intact Fibula
The fibula is a bone that will bend without obvious fracture. If you doubt this,
take an x-ray of the normal leg in a child with an angulated tibial fracture (with
no fibula fracture), and compare the shape of the fibula on each side. Fracture
of the tibia in children is more commonly associated with an intact, if bent,
fibula.
The intact fibula struts the bone ends apart. Varus deformity with posterior
bowing is a common sequela unless the cast is molded into valgus with added
posterior molding to prevent recurvatum (Fig. 15-11). The bowing may not be
apparent in initial films but commonly develops in the course of 2 or 3 weeks if
the cast is not suitably molded. It is a deformity more easily prevented than cor-
rected.
Tibia Fx
Fx—Tibia and Fibula Fibula Intact
After Reduction
Figure 15-11. The intact fibula struts the bone
apart. Varus deformity is a common sequela un-
less the cast is molded into valgus.
Toddler’s Fracture 223
Common Variations
Children younger than the age of 2 years may present with a painful limp or re-
fusal to walk due to an. occult tibia fracture. The injury may or may not have
been witnessed. Toddlers often fall and a rotational stress can cause an oblique
distal tibia fracture. The presence of fever, constitutional symptoms, or associ- At Injury 3 weeks later
ated illnesses should prompt further workup.
The examination should start on the uninvolved side to provide a comparison
for the symptomatic extremity. The examination begins at the hip and proceeds
down to the foot. The area of pain is often poorly localized. It is important to
note areas with an increase in local temperature and any swelling or bruising.
AP and lateral radiographs of the tibia and fibula should be obtained but are
often normal (Fig. 15-12). The fracture may not be visible on the initial radi-
ographs especially if the injury is less than a week old. If a toddler’s fracture of
the tibia is suspected but the x-ray is normal, we usually get a complete blood
count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-re-
active protein (CRP) to rule out infection. If the laboratory studies are normal
we then apply a long leg walking cast for 3 weeks. Repeat radiographs in 3
weeks will often show periosteal new bone formation, which helps to confirm
the diagnosis.

Open Fractures
Figure 15-12. Toddler’s fracture. The
Open fractures are usually the result of being hit by a car or some type of mo-
oblique fracture line on the injury film is
torized vehicle all terrain vehicle (ATV). The wounds are often small and repre- very hard to see. The child was treated
sent a puncture wound from within. They should be treated with thorough with a long leg cast. Three weeks later the
débridement of the wound as soon as possible. presence of healing callus confirms the di-
In the emergency department, the patient’s tetanus status is updated as nec- agnosis.
essary and antibiotics are started. Antibiotic coverage and duration depends on
the grade of the open fracture and presence or absence of gross contamination.
Almost all patients are taken to the OR for irrigation and débridement. How-
ever, several centers are now studying the concept of treating grade I fractures
with ER cleansing plus intravenous antibiotics. Great experience and judge-
ment are required to elect this course.
In the OR, clean grade I and II open fractures can be stabilized with percuta-
neous pins, intramedullary nails, or plate and screws after the initial irrigation
and débridement. External fixation is often used for grade III fractures and
“External fixation is often
grossly contaminated grade II and III fractures. In the presence of more exten-
sive wounds or contaminated wounds, repeat débridement should be per- used for grade III fractures
formed every 48 hours until the wound is clean. and grossly contaminated
Fat embolism syndrome occasionally occurs in children and the treating sur-
geon must be aware of the potential (Limbard, Ruderman—see Suggested grade II and III fractures”
Readings). Pulmonary problems following a rather straightforward case should
raise suspicion.

Gillespie Fracture—Distal Tibia Diaphysis

Robert Gillespie of the Hospital for Sick Children—Toronto describes this pat-
tern (Fig. 15-13). This little-known fracture is worth recognizing, as it is a po-
tential source of grief. The injury appears to result from landing on a dorsi-
flexed foot. The anterior border of the tibia is crumpled while the posterior
surface opens, producing slight posterior angulation. Seemingly innocent at
first, by the time the cast is removed the angulation has increased to an unac-
ceptable degree. Cast the leg with the foot in equinus for the first 4 weeks to
224
Tibia
Figure 15-14. The term floating knee has
been proposed to describe the very unsta-
ble circumstance in which both the tibia
and the femur have complete fractures in
the same limb.
At Injury Cast with Ankle at 90˚ Cast in Equinus
Figure 15-13. The Gillespie fracture is a potential source of grief. Casting the fracture with
the ankle at neutral cause unaceptable angulation (recurvatum). To avoid this, the cast must
be applied with the foot in equinus.
prevent this problem. The cast can then be changed to one with a more neutral
ankle position for remaining healing.
Bicycle Spoke Injuries
Bicycle spoke injuries occur when a bicycle overturns and the child’s foot is
caught between the spokes of the turning wheel. This causes a severe crushing
injury to the soft tissues of the foot and ankle often with an associated lacera-
tion. A spiral fracture of the tibia can also occur. The child should be admitted
to the hospital when the soft tissue damage is severe. When a tibia fracture is
present, initial immobilization should consists of a widely univalved or bivalved
non-weight bearing cast to allow for swelling.
The Floating Knee
The term floating knee has been proposed to describe the very unstable circum-
stance in which both the tibia and femur have complete fractures in the same
limb (Fig. 15-14). The usual mechanism of injury involves a pedestrian struck
by a car or a motor vehicle accident.
General treatment considerations include age, polytrauma injuries, closed or
open fracture, and the physician’s experience. Operative intervention is recom-
mended. Depending on the age of the child, both fractures can be treated with
flexible intramedullary nails. Alternatively, the femur fracture can be treated
with flexible nails and the tibia fracture with crossed percutaneous pins.
Fractures in Paraplegic Children
Tibial fractures are not unusual in children with neurologic conditions (cerebral
palsy, muscular dystrophy, spinal bifida, spinal cord injury). In this population,
tibia fractures are usually nondisplaced and result from relatively minor trauma
(such as a fall from a wheelchair). They are also common after cast immobiliza-
tion for reconstructive surgery (due to preexisting osteopenia made worse by
casting). Displaced fractures are treated with reduction and immobilized for 3
to 4 weeks. In the face of severe osteopenia or repetitive insufficiency fractures,
patients should be referred to endocrinology for consideration of medical ther-
apy (sometimes with intravenous biphosphonates).
 Stress Fracture with 225
Delayed Diagnosis After Cast Immobilization Distal Metaphyseal Fractures

Figure 15-15. Stress fractures occur when normal bone is subjected to repetitive mi-
crostresses below the usual threshold needed to cause an acute fracture. In this case, diagno-
sis was delayed and moderate anterior bowing occured. Often stress fractures can be
treated with a decrease in activity.

Stress Fractures
Stress fractures are often associated with poor conditioning prior to sport activ-
ity, a sudden change in distance running; and tight heel cords, hamstrings; and
quadriceps (Fig. 15-15).
Stress fractures occur when normal bone is subjected to repetitive mi-
crostresses below the usual threshold needed to cause an acute fracture. In this
setting, osteoclastic bone resorption exceeds osteoblastic activity and bone dep-
osition. Most tibia stress fractures in children occur in the proximal third with a
peak age incidence between 10 and 15 years. In contrast, pediatric stress frac-
tures typically occur between the ages of 2 and 8 years and are localized to the
distal third of the fibula.
If not readily apparent on plain radiographs, a three-phase bone scan or MRI
can facilitate the diagnosis. Treatment can begin with activity restriction only in
a very cooperative patient. Other treatment modalities may include protected
weight bearing with crutches and immobilization in a walking brace or cast for
4 to 6 weeks.
A gradual return to activities is then recommended with a lower extremity
strengthening and stretching program. Although rare, nonunions of stress frac-
tures typically in the middle third of the tibia may occur. This requires use of
electromagnetic stimulation or excision of the nonunion, iliac crest grafting and
compression plating, or intramedullary fixation.

DISTAL METAPHYSEAL FRACTURES

Distal metaphyseal buckle fractures are common in children and are usually
treated with a cast for 3 to 4 weeks.
Distal tibia physeal injuries are also very common and are presented in
Chapter 16.
Suggested Readings
Aronson DD, Stewart MC, Crissman JD:
Experimental tibial fractures in rabbits
simulating proximal tibial metaphyseal
fractures in children. Clin Orthop
255:61, 1990.
Balthazar DA, Pappas AM: Acquired valgus
deformity of the tibia in children. J Pedi-
atr Orthop 1984;4:538–541.
Briggs TW, Orr MM, Lightowler CD: Iso-
lated tibial fractures in children. Injury
1992;23:308–310.
Buckley SL, Smith G, Sponseller PD, et al:
Open fractures of the tibia in children. J
Bone Joint Surg 1990;72A:1462–1469.
Burkhart SS, Peterson HA: Fractures of the
proximal tibial epiphyses. J Bone Joint
Surg 1979;61A:996–1002.
Chow SP, Lam JJ, Leong JC: Fracture of the
tibial tubercle in the adolescent. J Bone
Joint Surg 1990;72B:231–234.
Hansen BA, Greiff J, Bergmann F: Fractures
of the tibia in children. Acta Orthop
Scand 1976;47:448–453.
Hope PG, Cole WG: Open fractures of the
tibia in children. J Bone and Joint Surg
1992;74B:546–553.
226
Kreder HJ, Armstrong P: A review of open
tibia fractures in children. J Pediatr Or-
thop 1995;15:482–488.
Limbard T, Ruderman R. Fat embolism in
children. Clin Orthop 136:267–268,
1978
Navascués JA, Gonzáles-López JL, López-
Valverde S, et al. Premature physeal clo-
sure after tibial diaphyseal fractures in
adolescents. J Pediatr Orthop 200;20:
193–6.
Ogden JA, Ogden DA, Pugh L, et al: Tibia
valga after proximal metaphyseal frac-
tures in childhood: A normal biologic re-
sponse. J Pediatr Orthop 1995;15:
489–494.
Qidwai MS: Intramedullary kirschner wiring
for tibia fractures in children. J pediatr
Orthop 2001;21:294–7.
Shannak AO: Tibia fractures in children:
Follow-up study. J pediatr Orthop 1988;
8:306–310.
Shelton WR, Canale ST: Fractures of the
tibia through the proximal tibial epiphy-
seal cartilage. J Bone Joint Surg 1979;
61A:167–173.
Taylor SL: Tibial overgrowth: A cause of
genu valgum. J Bone Joint Surg 63B:83,
1981
Tuten HR, Keeler KA, Gabos PG, Zionts
LE, Mackenzie WG. Posttraumatic tibia
valga in children. J Bone Joint Surg 81A:
799, 1999.
Weber BG. Fibrous interposition causing
valgus deformity after fractures of the
upper tibial metaphysis in children. J
Bone Joint Surg (Br) 59:290, 1977.
Yang JP, Letts RM: Isolated fractures of the
tibia with intact fibula in children: A re-
view of 95 patients. J Pediatr Orthop
1997;17:347–51.
Zionts LE, MacEwen GD: Spontaneous im-
provement of post-traumatic tibia valga. J
Bone Joint Surg 1986;68A:680–687.
 16Ankle
François Lalonde m Maya Pring

• Applied Anatomy 228

• Radiographic Issues 228
• Classification 229
• Nonarticular Fractures 231
• Tillaux Fractures 235
• Triplane Fractures 235
• Malleolar Fractures 238
• Syndesmosis Injuries 240
• Ankle Sprains 241

INTRODUCTION
In 1898, John Poland made an extensive study of epiphyseal separations about
“The source for
the ankle. He noted that ankle injuries in children differed from those in adults
in three important ways:
happiness is one of
1. The growth plate forms a plane of weakness directing fracture lines in pat- the chief sources of
terns different from those of adults.
2. Ligaments are stronger than bone so that ligamentous injuries are less com-
unhappiness”
mon in children.
3. Certain injuries will affect growth.
—ERIC HOFFER
To Poland's observations the following should be added:

227
228 4. Fractures rarely disturb the talo-tibial relationship, so that persistent disabil-
Ankle ity owing to incongruity is unusual.
5. From the age of 14 to 15 years onward, when the growth plate has closed,
the adult pattern of fractures emerges.

APPLIED ANATOMY
The ankle joint is comprised of the talus, which articulates with the ankle mor-
tise. The mortise is formed by the distal tibia and the lateral and medial malleolus.
The three major groups of ligaments are each attached to an epiphysis (deltoid,
tibio-fibular, tibio-talar) (Fig. 16-1) and provide stability for the articulation.
The distal tibia physis closes around the age of 15 years in girls and 17 in
boys. The asymmetric closure of the physis is responsible for many of the frac-
tures that will be discussed in this chapter (Fig. 16-2). Closure proceeds in two
directions from an initial site in the near central area. This is followed by fusion
of the posteromedial and finally the anterolateral segments of the growth plate.
The distal fibula physis closes approximately 1 year later.
When the foot is forced into an abnormal position, tension and compression
forces are generated across the ankle. The structure of the ankle appears to per-
mit tension injuries most frequently with the result that avulsion injuries of the
epiphyses are common. Compression fractures are unusual.

RADIOGRAPHIC ISSUES
Many people assume that there is no fracture if the x-ray appears normal. How-
ever, undisplaced epiphyseal separations show no fracture. The clinical signs

Posterior
Anterior
talofibular
talofibular
ligament
Posterior ligament
talofibular
ligament

Posterior
Calcaneo- talo-tibial
fibular ligament
ligament Calcaneo-fibular
ligament

Figure 16–1. Strong ankle ligaments attached to the epiphyses account for epiphyseal sep-
aration being more frequent than epiphyseal fractures.

A B C D
Figure 16-2. Progression of normal distal tibial physeal closure at puberty. A) Begins centrally. B)
Spreads medially. C) Then laterally. D) Until complete closure.
and localized soft tissue swelling on the x-ray should be sufficient to sustain the AP View
diagnosis. On occasion, there may be widening of the physis when comparison
is made with x-rays of the uninjured ankle.
We have missed some fractures about the ankle when we relied on only two
views of the ankle (Fig. 16-3). Always take a mortise view (Table 16-1). The
mortise x-ray is taken from anterior to posterior with the foot internally rotated
20°; on this view, the outline of the talus is visualized with a symmetric space
around it. Asymmetry indicates ligamentous injury and ankle instability.
Mortise View
X-ray measurements of the tibiofibular line, talocrural angle, talar tilt, and
medial clear space can be made from the standard mortise view to help deter-
mine stability and plan treatment.

CLASSIFICATION
The pattern of injury to the ankle depends on many factors, including the age
of the patient; the quality of the bone; the position of the foot at the time of in-
jury; and the direction, magnitude, and rate of the loading forces. In children,
the Salter-Harris method still remains the most widely accepted classification Figure 16-3. This fracture is much more
scheme for ankle fractures (Table 16-2). visable in the mortise view than in the AP.
The mortise view shows a type IV fracture
that will require surgical reduction.

Table 16-1 The Mortise X-ray

Tibiofibular Line Tilt of the Talus Talocrural Angle Tib/Fib Clear Space

The tibiofibular line should Tilt of the talus in the mortise Talocural angle is normally 8°–15° 4 mm is normal widening
be congruent and parallel to indicates instability !8° or 2° difference from other side indicates syndesmotic
each surface of the talus indicates fibular shortening disruption

Table 16-2 Salter-Harris Classification

S.H. I S.H. II S.H. III S.H. IV S.H.V S.H.VI

Fracture through Fracture through Fracture through Fracture through Compression fracture Perichondrial ring
physis physis extending physis extending epiphysis and through physis not injury (lawn mower)
through metaphysis through epiphysis metaphysis crossing extending to epiphysis
the physis or metaphysis

229
230 Much of our current understanding of the mechanisms of ankle injury (Figs.
Ankle 16-4, 16-5) is derived from the work of Lauge-Hansen who emphasized the in-
fluence that the position of the foot (supination or pronation), and the direc-
tion that the deforming forces (adduction, external rotation, or abduction) have
on the fracture pattern (Table 16-3). These adult descriptions are often used to
describe children’s fractures (with only partial success).
Distal fibula fractures and associated syndesmosis injuries are common and
can be classified using the Danis-Weber system. The Salter-Harris system suf-
fices for most children’s orthopedic descriptions for ankle fractures.

Figure 16-4. Supination—adduction of Figure 16-5. Pronation—

the foot causes this injury. external rotation of the
foot causes this injury.

Table 16-3 Lauge-Hansen Classification

This classification (see Suggested Readings) is learned by all orthopedic surgeons and helps to understand fracture mechanisms but is
rarely used in day-to-day children’s fracture care.

Supination-Adduction Supination-External Rotation Pronation-Abduction Pronation-External Rotation

NONARTICULAR FRACTURES 231
Nonarticular Fractures
Salter-Harris Type I and II Fractures of the Fibula
Types I and II are by far the most common injuries to the fibula. They are recognized
by swelling and tenderness over the growth plate. In a Type I injury, the radiographs
are usually normal (Fig. 16-6). Stress films under anesthesia will demonstrate injury
but are unnecessary as a routine, and we neither use nor advocate this technique.

Treatment
The majority of Salter-Harris Type I distal fibular fractures are nondisplaced
and can be treated in a walking cast for 3 weeks to allow comfortable healing. If
no cast is applied, the injury will heal, but the parents, watching their child hop
around on crutches, will be an endless source of trouble to you because of their
unrelieved concern and the very small chance that the fracture will displace.
When the cast is removed, movement quickly returns, and sequelae are rare.
Displaced Salter-Harris I and II fractures require reduction. Definitive treat-
ment usually depends on the presence of other associated ankle fractures and
Figure 16-6. Salter-Harris I fractures may
the quality of the reduction. In widely displaced fractures, there may be soft tis-
be difficult to diagnose on x-ray. The clini-
sue interposition (peroneal tendons or periosteum) blocking adequate reduc- cal exam is much more telling. This child
tion. In this instance, open reduction and internal fixation with cross or longi- had focal pain over the distal fibular physis
tudinal K-wires is helpful. Fixation of the fracture with a K-wire may be and was assumed to have a type I injury.
required after closed manipulation if the reduction is unstable. Standard treatment is a short leg walking
cast.

Salter-Harris Type I Injury of the Tibia

Type I injuries of the tibial physis do occur but are less common. Diagnosis of “The majority of Salter-
undisplaced fractures is based on clinical exam—tenderness and swelling directly
over the physis. Sometimes, the injury cannot be recognized on radiographs
Harris Type I distal fibular
until subperiosteal new bone appears after 3 weeks. These fractures are usually fractures are nondisplaced
treated in a below knee cast for 3 weeks. The rare displaced fracture requires re- and can be treated in a
duction and a non-weight-bearing cast for a longer period of time (6 weeks).
walking cast for 3 weeks to
Salter-Harris Type-II Injury of the Tibia allow comfortable healing”
Type II injuries typically result from higher energy; the force is most commonly
supination-plantar flexion or abduction (Fig. 16-7). Gross displacement some-

At Injury Post Reduction

Figure 16-7. The typical Salter-Harris II fracture of the

distal tibia was treated with closed reduction and casting.
232 times produces ischemia of the foot, which can be relieved prior to transfer or
Ankle definitive treatment by partially reducing the fracture with the help of longitu-
dinal traction and splinting. Usually, this initial step leads to improved circula-
tion to the foot with palpable pulses by finger or Doppler.
At Injury
Treatment
The rare nondisplaced fracture can be treated in a below-knee walking cast for 4
to 6 weeks. Patients are followed with x-rays at 6 and 12 months post fracture
to rule out physeal arrest.
Closed reduction of Salter-Harris II fractures of the tibia can be done either
in the emergency department using conscious sedation or in the operating
room under general anesthesia. Greater muscle relaxation with general anesthe-
sia and superior imaging capabilities in the operating room often facilitate the
reduction and reduce the number of attempts made at reduction, perhaps de-
Post-op
creasing the chance for physeal arrest (Fig. 16-8).
As described for reduction of tibia shaft fractures, reduction of an ankle frac-
ture is often made easier with the knee flexed over the end of the bed. First, the
force of injury is recreated with plantar flexion and supination or abduction.
Longitudinal traction is then applied to the foot and ankle with an assistant
providing counter-traction at the knee. While maintaining traction, the reduc-
tion is achieved by bringing the foot around and into a neutral position. Inter-
nal rotation will help to keep the fracture reduced. The adequacy of the reduc-
tion is checked initially by fluoroscopy and any adjustments are made.
6 Month
Frequently, complete reduction of Salter-Harris II fractures of the tibia is lim-
Follow Up
ited by entrapped soft tissues (usually periosteum) at the fracture site; this is
identified when the physeal gap is wider than on the contralateral x-ray (Fig.
16-9)
If the reduction is deemed adequate, a long leg cast is applied in two stages,
then split to allow for swelling. AP lateral, and mortise x-rays of the ankle are
then obtained in cast to document the reduction. Ankle x-rays should be ob-
tained rather than x-rays of the entire tibia/fibula as they demonstrate the re-
duction more accurately. For comparison, the opposite ankle should also be x-
Figure 16-8. This abduction type Salter- rayed so that precise measurement of the difference in physeal gap or step-off
Harris II fracture of the distal tibia required
can be evaluated. The length of time in the cast is usually 6 weeks with weight
open reduction and fixation. The Harris
growth line (arrow) on the follow-up x-ray bearing restricted for the first 3 to 4 weeks.
shows that the physis continued to grow There is current debate regarding whether open reduction of the fracture
normally following the fracture. with removal of entrapped soft tissues and stabilization of the fracture with ei-

At Injury

After ORIF
After Initial Reduction

Figure 16-9. This Salter-Harris II fracture could not be reduced completely—a significant amount of periosteum was blocking reduction
(arrow). At open reduction, the entrapped periosteum was removed, allowing anatomic reduction. Mubarak and colleagues (see Suggested
Readings—Barmada et al.) have found that anatomic reduction reduces the risk of physeal closure.
 233
Distal Tibia Physeal Fractures Nonarticular Fractures
Suggested Clinical Pathways
Salter-Harris I, II and Triplane distal tibia fractures
Mandatory radiographs
• Contralateral films
• Hand for bone age—(younger children—greater risk for deformity if physis
closes)

ther crossed K-wires or screws can decrease the incidence of physeal arrest (Figs.
16-9, 16-10). In patients that are skeletally immature (girls !12; boys !14),
advocates of open reduction may intervene surgically in patients with "2 mm
Periosteum
difference in physeal gap or translation (compared to the contralateral x-ray)
and more than 2 years of growth remaining. The clinical pathway that we fol-
low is presented here.

Pitfalls—Nonarticular Distal Tibial Fractures

Physeal closure occurs more commonly in Salter-Harris I and II fractures of the
distal tibia than previously reported. In a recent study of 147 skeletally imma-
ture patients with distal tibia Salter-Harris I/II fractures, Mubarak and
Rohmiller et al. found a 38% incidence of physeal arrest overall. On further
analysis of the direction of the force at the time of injury, it was found that
supination-external rotation (SER) injuries have a slightly better prognosis than
Figure 16-10. The periosteum is firmly
abduction type injuries. The rate of physeal closure can be affected by surgical
attached to the epiphysis—it often pulls off
intervention in SER injuries; the rate of closure in patients treated without sur- the metaphysis and becomes entrapped in
gery was 56%, whereas those who had open reduction had a physeal closure the fracture—preventing complete reduc-
rate of only 16%. tion.
234
Ankle Kump’s Bump
Warren Kump, a Minneapolis radiologist, first published a paper describing the mound-shaped medial undulation on the
distal tibial physis. Oddly enough, this is now referred to as “Kump’s bump.” Kump noted that natural physeal closure be-
gins “medio-centrally” in this area.The medial does close earlier than the lateral, predisposing to the Tillaux type fracture.
Others believe that this prominence may be prone to shear injury with a physeal fracture, predisposing to physeal clo-
sure. (Kump WL.Vertical fractures of the distal tibial epiphysis—see Suggested Readings.)

Abduction
Injury

Normal Tibia
A B
Figure 16-11. A) Normal tibia showing Kump’s bump. B) Distal tibia-fibula fracture. Note the tibial metaph-
ysis may scrape through Kump’s bump causing physeal closure.

Abduction injuries, however, appear to have a higher rate of closure (52%),

which in this study was not changed significantly with surgical intervention
(54.5% closure in patients treated closed vs. 50% closure rate in patients treated
operatively). One possible explanation for this is that the abduction injuries rep-
resent higher energy shearing forces to the physis with probable disruption of
Kump’s bump at the time of injury (Fig. 16-11). Regardless of type of treatment,
patients with Salter-Harris injuries to the distal tibia require close follow-up with
x-rays for a minimum of 1 year after injury to follow the growth of the physis.

At Injury
Extensor Retinaculum Syndrome
The extensor compartment of the ankle, deep to the retinaculum, is vulnerable
to increased pressures in association with distal tibia physis fractures. This often
occurs when the foot is caught between the ground and the pedal of a bicycle or
motorbike causing a distal tibia fracture with. apex anterior angulation. Struc-
tures that travel within the extensor compartment include the long toe exten-
sors, the anterior tibial artery, and the deep peroneal nerve.
After ORIF
Signs of extensor retinaculum syndrome include severe pain and swelling of the
ankle, hypoesthesia or anesthesia in the web space of the great toe, weakness of ex-
tensor hallucis longus and extensor digitorum communis, and pain on passive flex-
ion of the toes, especially the great toe. A high index of suspicion is required (Fig.
16-12). If suspected, the extensor compartment pressure should be measured. In-
terpretation of elevated pressure is similar to that described for compartment syn-
drome. If the measured pressure is elevated, surgical intervention is warranted with
release of the superior extensor retinaculum and stabilization of the fracture.

Figure 16-12. This patient has significant

swelling and developed an extensor reti-
naculum syndrome. Release of the exten-
sor retinaculum at the time of surgery re-
lieved his symptoms.
234
Salter-Harris Type VI Injuries—
Ablation of the Perichondrial Ring
Lawn mower and degloving injuries may remove the perichondrial ring. Lip-
mann Kessel has shown that this permits a callus bridge to form between the
epiphysis and metaphysis with resulting varus deformity and failure of growth. 235
The severity of this injury may be missed on initial x-rays. The Triplane Fracture

THE TILLAUX FRACTURE

The Tillaux fracture almost always occurs in the adolescent within a year of “Regardless of type of
complete closure of the distal tibial physis (Fig. 16-13). The central and medial treatment, patients with
aspects of the physis have closed, leaving the anterolateral aspect open and vul-
nerable to injury. An external rotation force on the foot may avulse the antero-
Salter-Harris injuries to the
lateral quadrant of the tibial epiphysis, which is bound to the fibula by the distal tibia require close
strong anterior tibiofibular ligament, resulting in a rectangular or pie-shaped follow-up with x-rays for a
fragment being broken off of the distal tibial epiphyis. A mortise view is essen-
tial with this fracture as the fibula may obstruct its visualization. The true minimum of one year after
amount of displacement is often best appreciated on the lateral view provided injury to follow the growth
the lateral view is taken correctly.
Kleiger and Mankin noted that rotatory instability, detectable by an exami-
of the physis”
nation under general anesthetic, is a feature of this fracture. Therefore the frac-
ture may reduce with internal rotation and supination of the foot and thumb At Injury
pressure over the displaced anterolateral fracture fragment. An above-knee cast
is applied in two stages with the foot in supination and internal rotation. Post-
reduction x-rays (AP, lateral, mortise) are taken to assess the adequacy of the re-
duction. If the amount of residual displacement remains in question after re-
view of the x-rays, a CT scan of the ankle is helpful. No displacement should be
accepted.
Nondisplaced fractures are treated in a non-weight-bearing above-knee cast
for 3 weeks, followed by a below-knee walking cast for another 3 weeks. When
displacement is present, open reduction and internal fixation is necessary
through an anterolateral approach. After reduction, fixation is achieved using
one or two cancellous screws, crossing the fracture line in a perpendicular fash- CT Image
ion; the screw can cross the physis because the physis is in the process of closing.

THE TRIPLANE FRACTURE

The tibial triplane fracture is a complex fracture defined by sagittal, transverse,
and coronal components that courses in part along and in part through the
physis and enters the ankle joint (Fig. 16-14). As pointed out by Von Laer, these

Figure 16-13. A minimally displaced

Tillaux fracture is better visualized with
CT. This fracture was treated with a cast,
often analyzing the amount of displace-
ment of the CT scan.

“The Tillaux fracture

almost always occurs in the
adolescent within a year of
complete closure of the distal
Figure 16-14. Two fragment and three fragment triplane fractures. tibial physis”
236
Ankle The Tillaux Fracture

Anatomy of the Tillaux fracture. Characteristically, the fracture is difficult to see.

Paul Jules Tillaux

1834–1904
Tillaux, a Parisian surgeon, is credited
with first understanding this fracture.
His description was originally drawn
on a scrap of paper.The drawing was
found after he died by Chaput, who
made the best of the ambiguous
sketch.
Frequently the fracture line is overlaid by the fibula.

Open reduction and fixation allows restoration of the joint space.The young fibula is pli-
able and rarely fractures. In the usual Tillaux fracture, the fibula probably bends and then
springs back, returning the fragment into place.

“...these fractures with their

complicated course of
fracture lines in different
planes, challenge the
imagination of the surgeon”
fractures with their complicated course of fracture lines in different planes,
challenge the imagination of the surgeon. The triplane fracture also occurs as a
result of the special anatomic circumstances surrounding the nature of closure
of the distal tibial growth plate. Most fractures are the result of an external rota-
tion of the foot on the leg. Less commonly, an internal rotation force can pro-
duce a medial triplane fracture.
 Classically, this fracture appears as a type III injury in the AP x-ray and as a 237
type II injury on the lateral view. Radiographs are hard to interpret. A CT scan The Triplane Fracture
is an invaluable tool in defining the fracture configuration and the amount of
intra-articular displacement (Fig. 16-15).
It is the lateral part of the epiphysis that tends to be involved more com-
monly, as in the Tillaux fracture. Medial triplane fractures can occur in children
prior to fusion of the medial physis. Most classification systems are based on
three factors: (1) medial or lateral, (2) number of parts, and (3) intra- or extra-
articular. Fractures of the fibula may be seen with any triplane fracture. Not un-
commonly, triplane fractures can be seen in conjunction with ipsilateral tibial
shaft fractures. Three-part fractures have a propensity for intra-articular incon-
gruity. These types of fractures often leave a posterior metaphyseal-epiphyseal
fragment that behaves like a Salter-Harris IV fracture. This fragment may mi-
grate proximally leaving a residual step in the joint surface.
Neurovascular compromise is rare. Occasionally, in widely displaced fractures,
tenting of the skin over the fracture fragment may lead to skin necrosis if reduction is
not carried out expediently. Accurate closed reduction is the usual mainstay of treat-
ment. Reduction is performed either under conscious sedation or general anesthesia
for optimal relaxation and is achieved by traction and internal rotation of the foot,
usually with the foot in plantar flexion. The exception is the rare medial fracture,
which may require external rotation. Overly aggressive internal rotation and forceful
dorsiflexion before the distal fragment is reduced can fracture the anterolateral beak
of the epiphysis, which then converts a two-part fracture into a three-part fracture.
Once closed reduction is achieved, a long leg cast is applied with the foot in
internal rotation (not varus). The patient is kept non-weight-bearing for about
3 weeks, then transitioned into a short leg or patellar tendon weight-bearing
cast for an additional 2 to 4 weeks.
Maximum acceptable residual displacement is 2 mm at the articular surface.
For the extra-articular variant, less stringent requirements may apply. Open re- Figure 16-15. A 3-D CT scan often helps
duction is often necessary for medial fractures and some three-part fractures to understand the pattern of a triplane frac-
(Fig. 16-16). CT scans are extremely helpful in planning operative intervention. ture and helps to plan surgical correction.

At Injury Additional Film After ORIF

Figure 16-16. Triplane fractures may have more proximal associated fractures. In this case, initial films showed a triplane fracture with ex-
tension to the tibial shaft.The proximal fibular fracture was missed on the initial x-rays, because the entire tibia-fibula was not included on the
film. The triplane fracture required ORIF.
238
Ankle
“In a young child, the lateral
cartilaginous model can be
avulsed by a ligament.
Initially there is just swelling,
and radiographs are normal.
After a month or more, the
cartilage model forms an
ossicle”
Normal Original Injury Later
Figure 16-17. The distal tip of the fibula
may be avulsed by the attached ligament.
Note the well-rounded ossical distal to the
fibular tip—this is the late consequence of
an earlier avulsion fracture.
Typically, the lateral triplane fracture is approached using an anterolateral inci-
sion for the free anterolateral epiphyseal fragment. A second posterior incision
may be medial or lateral depending on the fracture configuration. Interfrag-
mentary screws are usually used for fixation with occasional plating of displaced
fibular fractures.
MALLEOLAR FRACTURES
Provided one has a good understanding of the mechanism of injury and inher-
ent stability of the injury, closed reduction can be attempted under oral or in-
travenous analgesia and/or sedation. Closed reduction is obtained by reversing
the mechanism of injury to the ankle and then bringing it into a reduced posi-
tion while maintaining traction on the foot. Post-reduction x-rays are essential
to assess stability and the quality of the reduction. The majority of pediatric
malleolar fractures can be treated with casting.
Operative treatment of ankle fractures is recommended when:
! Closed reduction fails
! Maintaining closed reduction requires forced, abnormal positioning of the
foot, such as forced plantar flexion and inversion
! There is displacement of the talus or widening of the mortise greater than 1
to 2 mm
! Displaced fractures involve the articular surface
! The fracture is open
The surgical procedure is carried out as soon as possible but is dependent on
evaluation of the entire patient, the condition of the soft tissues, and the amount
of swelling present. Initially, the ankle should be gently reduced and immobi-
lized in a padded splint to prevent further soft tissue injury and to decrease
swelling. Ice and elevation are used to reduce swelling until operative treatment
can be safely performed. Ankle swelling usually peaks between day one and
seven, and operative treatment is best done before the period of maximal
swelling or after the initial swelling has resolved. The “wrinkle” test is commonly
used to determine if swelling is likely to prevent skin closure following surgery.
Lateral Malleolus
In a young child, the lateral cartilaginous model can be avulsed by a ligament.
Initially, there is just swelling, and radiographs are normal. After a month or
more, the cartilage model forms an ossicle (Fig. 16-17). The anterior talofibular
ligament pulls a fragment off the anterior fibula; this is the adolescent equiva-
lent to an adult ligament rupture. Occasionally, the ossicle remains sympto-
matic and can be excised with relief.
Often, the original injury occurs at a young age (age 4-10 years) and the pa-
tient appears later with symptoms (now ossified). This condition is often con-
fused with a normal ossification variation (os subfibulare).
Most avulsion fractures of the lateral malleolus can be treated closed by
everting the ankle to relax the lateral collateral ligaments prior to reducing the
fracture. The fracture is then immobilized in a short leg cast for 4-6 weeks.
Weight bearing is started once the initial symptoms subside. An associated frac-
ture of the medial malleolus makes closed treatment more difficult.
External rotation fractures at the level of the syndesmosis (SER) are reduced
by gentle distraction, internal rotation, and varus stress (Fig. 16-18). A cast is
then applied with the foot in this position. Residual shortening and external ro-
tation of the fibula may be difficult to appreciate on post-reduction films. More 239
severe injuries requires surgical reduction (Fig. 16-19). Malleolar Fractures
The lateral malleolus is approached through an anterolateral or posterolateral
approach. Depending on the skeletal maturity of the patient, there are many
options for fixation. In young children, a longitudinal or crossed K-wire is suffi-
cient. An oblique fracture that is longer than two times the diameter of the
bone can be fixed with lag screws alone. An external rotation oblique fracture of
the distal fibula at the level of the syndesmosis can be stabilized with lag screws
alone or more commonly a plate to neutralize the rotational and axial forces on
the fibula. The one-third tubular plate conforms better to the fibula and has a
lower profile than the thicker compression plate. Fractures above the syndesmo-
sis are stabilized with a one-third tubular plate with or without lag screws.
In treating deltoid ligament injuries in association with a fracture of the lateral
malleolus, it is generally accepted that an anatomic reduction of the fibula and
talus restores the medial anatomy and will allow the medial ligamentous struc-
tures to heal without need for operative repair. Anatomic restoration of the fibula
usually restores the talus to its normal position. If, however, the medial clear
space remains widened by more than 2 mm after reduction of the fibula, or the
reduction of the fibula is blocked, then the medial side should be explored.

Medial Malleolus
Figure 16-18. Closed reduction of a dis-
Avulsion fractures of the medial malleolus are rare and must be distinguished tal fibular (lateral malleolar) fracture is
from variations of ossification. True displaced medial malleolus avulsion frac- best maintained with the application of an
tures require open reduction and internal fixation. internal rotation and varus moment to the
ankle-foot.
Isolated medial malleolus fractures are uncommon and the possibility of an
undisplaced lateral injury such as a Maisonneueve proximal fibula fracture
should be considered. Isolated fractures are treated closed if they are nondis-
placed, involve the distal portion of the malleolus, or can be anatomically re- At Injury
duced by manipulation. A CT scan may be necessary to ensure that the joint
surface is not disrupted if closed management is chosen.
Fixation for displaced medial malleolus fractures depends on the fracture
pattern and the patient’s age. In skeletally immature patients, reasonable efforts
should be undertaken not to cross the open physis. This can often be accom-
plished with two transepiphyseal cannulated or cancellous screws (Fig 16.20).

Salter-Harris III or IV?

At Injury

After ORIF

After ORIF

Figure 16-20. Displaced intra-articular

fractures of the medial malleolus require
ORIF. Often it is difficult to determine
whether this is a type III or IV injury.The
Thurston-Holland fragment may be very
small. Care should be taken not to put
screws across an open growth plate.
Figure 16-19. An external rotation
oblique fracture of the distal fibula at the
level of the syndesmosis can be stabilized
with lag screws alone or more commonly a
plate to neutralize the rotational and axial
forces on the fibula.
240
Ankle
“Asymmetry of the Harris
growth line is often an
important indicator of early
premature physeal closure”
At Injury After ORIF
Figure 16-22. Syndesmotic disruption
requires fixation of the syndesmosis. The
syndesmotic screw should be removed
after adequate healing (usually 3 months).
At Injury 6 Months Later
A B C
Figure 16-21. A) This Salter-Harris II injury underwent closed reduction and cast treat-
ment. B) CT scan 6 months later shows physeal arrrest of the right distal tibia. C) The x-rays
show valgus deformity, a physeal bar, and assymmetric Harris growth lines.
On occasion, the metaphyseal portion of the fracture is large enough to accom-
modate a transmetaphyseal screw.
When transepiphyseal fixation is not possible because of the location of the
fracture, it may necessary to use smooth K-wires across the physis with or with-
out tension-band wiring. Reduction may be hindered by trapped, loose frag-
ments that will require removal. In skeletally mature patients, medial malleolus
fractures are stabilized using two cancellous or cannulated screws inserted per-
pendicular to the fracture in the classic adult fashion.
Pitfalls—Physeal Fractures of the Distal Tibia
In skeletally immature patients, premature physeal closure is common after dis-
tal tibia fractures (Fig. 16-21), especially those involving with the medial malle-
olus. The potential impact of distal tibia physeal arrest on limb-length inequal-
ity and angular deformity at the ankle depends on the growth remaining.
Patients are usually followed at 6 months and 1 year post injury with radi-
ographs of the involved ankle. If the patient is close to skeletal maturity, or to
assist in interpretation of possible physeal closure, x-rays of the non-injured
ankle may be helpful.
Asymmetry of the Harris growth line is often an important indicator of early
premature physeal closure. If premature physeal closure is documented by x-rays,
one should obtain a left hand x-ray for bone age and either an MRI or CT scan
to document more precisely the extent and location of the physeal arrest. De-
pending on the growth remaining, treatment of premature physeal arrest may
consist of close observation with serial x-rays, excision of the physeal bar with in-
terposition material; epiphysiodesis of the remaining open tibia physis, ipsilateral
distal fibula, and/or contralateral tibia and fibula; or corrective osteotomy.
SYNDESMOSIS INJURIES
Fractures associated with syndesmotic disruption (pronation-abduction/exter-
nal rotation) are usually unstable and most require operative stabilization (Fig.
16-22). The decision to use syndesmotic fixation is based on the fracture pat-
tern and intraoperative assessment of stability. Fixation is recommended when:
! There is medial ligamentous injury, syndesmotic disruption, and talar shift 241
without a fracture of the fibula (tibiofibular diastasis) Ankle Sprains
! When the treatment of a high fibula fracture (Maisonneuve fracture) is di-
rected primarily at stabilization of the syndesmosis and ankle mortise
! When there is continued evidence of syndesmotic instability after fixation of
the fibula and any avulsion fracture(s) of the tubercles or medial malleolus Colton test .

Intraoperative assessment of stability involves placing a hook around the

fibula at the level of the syndesmosis and applying lateral traction. Lateral
movement of the intact or internally fixed fibula or widening of the mortise on
intraoperative x-rays are indications for a syndesmotic screw.
If indicated, one or two (3.5 or 4.5 mm) cortical screws are used to hold but
not compress the syndesmosis. The screw is inserted just above the level of the
tibiofibular ligaments. It is recommended that the foot be placed in dorsiflexion
at the time of screw insertion to bring the widest portion of the talus into the
mortise. Both cortices of the fibula and the lateral cortex of the tibia are drilled,
tapped, and engaged by the screw(s). Patients with syndesmotic injuries should
be kept non-weight-bearing for 6 to 8 weeks. Although controversy exists, we
favor removal of the syndesmosis screw(s) prior to weight bearing.

ANKLE SPRAINS
Figure 16-23. Stress view indicating ankle
Ankle sprains are very common injuries that result from an inversion stress to sprain.
the ankle. The ligaments most commonly affected are the anterior talofibular
ligament and the calcaneo-fibular ligament. In skeletally immature patients,
this injury must be differentiated from the Salter-Harris I or II distal fibula frac-
ture. Both present with swelling and ecchymosis over the anterolateral aspect of
the ankle but the point of maximum tenderness helps to differentiate these two
injuries.
Ankle sprains are commonly graded according to severity. A grade I sprain
indicates that the ligaments are in continuity, grade II refers to a partial tear of
the ligaments, and grade III denotes a complete tear of the ligaments with gross
instability. Ankle sprains can be treated in a number of ways including an elastic
bandage, an aircast, a posterior splint, or a short leg cast. With mild and moder-
ate sprains, the patient is allowed to weight-bear as tolerated with or without
the help of crutches depending on the method of immobilization.
Recurrent ankle sprains may be due to residual ankle weakness, ligamentous
instability, or unsuspected tarsal coalition. In the non-acute setting, ligament
instability can be assessed on exam by the drawer test and inversion stress (Fig.
16-23) and by imaging such as stress radiographs and/or MRI.
If subsequent examination of the foot and ankle after injury reveals decreased
subtalar range of motion, one should suspect a tarsal coalition and AP, lateral, Figure 16-24. Recurrent ankle sprains
oblique, and axial (Harris) x-rays of the foot should be obtained (Fig. 16-24). A may be due to residual ankle weakness, lig-
talo-calcaneal coalition may be difficult to visualize on x-rays and a CT scan amentous instability, or unsuspected tarsal
may be helpful to make the diagnosis. coalition.
Suggested Readings
Barmada A, Gaynor T, Mubarak SJ: Prema-
ture physeal closure following distal tibia
physeal fractures. A new radiographic
predictor. J Pediatr Orthop 2003;23:733-
9.
Cameron HU: A radiologic sign of lateral
subluxation of the distal tibial epiphysis. J
Trauma 15: 1030, 1975
Canale ST, Belding RH: Osteochondral le-
sions of the talus. J Bone Joint Surg
1980;62A:97-102.
Danielsson LG: Avulsion fracture of the lat-
eral malleolus in children. Injury 12:165,
1980
Dias LS, Tachdjian MO: Physeal injuries of
the ankle in children: Classification. Clin
Orthop 1978; 136:230-3.
Ertl JP, Barrack RL, Alexander AH, et al: Tri-
plane fracture of the distal tibial epiph-
ysis: Long-term follow-up. J Bone Joint
Surg 1988;70A:967-76.
Horn D, Crisci K, Krug M, Pizzutillo PD,
MacEwen GD: Radiologic evaluation of
242
junvenile Tillaux fractures of the distal
tibia. J Pediatr Orthop 2001;21: 162-4.
Jarvis J: Tibial triplane fractures In: Pediatric
Fractures, Letts M ed.: 735-49, 1994
Kleiger B, Mankin HJ: Fracture of the lateral
portion of the distal tibial epiphysis. J
Bone Joint Surg 1964;46A:25-32.
Kling TF Jr: Operative treatment of ankle
fractures in children. Orthop Clin North
Am 1990;21: 381-92.
Kump WL. Vertical fractures of the distal
tibial epiphysis. Am J Roentgenol Ra-
dium Ther Nucl Med. 1966
Jul;97(3):676-81.
Lauge-Hansen N. Fractures of the ankle: an-
alytic historic survey as basis of new ex-
perimental, roentgenologic, and clinical
investigations. Arch Surg 1948;56: 259-
317.
Mooney J, Charlton M, Costello R,
Podeszwa D. Ankle joint contact pres-
sures after transepiphyseal screw fixation
of the distal tibia. POSNA 2004
Mubarak S: Extensor retinaculum syndrome
of the ankle after injury to the distal tibial
physis. J Bone Joint Surg 2002;84B:11-4.
Mubarak S: Salter Harris I/II fractures of the
distal tibia: Does operative treatment de-
crease the incidence of premature physeal
closure? (POSNA 2004)
Quigley TB: A simple aid to the reduction of
abduction-rotation fractures of the ankle.
Am J Surg 97:488, 1959.
Spiegel PG, Cooperman DR, Laros GS: Epi-
physeal fractures of the distal ends of the
tibia and fibula: A retrospective study of
two hundred and thirty-seven cases in
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60A:1046-50.
Vahvanen V, Aalto K: Classification of ankle
fractures in children. Acta Orthop Trau-
mat Surg 97:1, 1980
Von Laer L: Classification, diagnosis, and
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67A:687, 1985.
 17 Foot
François Lalonde m Dennis Wenger

• Phalangeal Fractures 243

• Metatarsal Fractures 245
• Tarsometatarsal Injuries 247
• Midfoot 248
• Calcaneal Fractures 249
• Subtalar Dislocation 249
• Talar Fractures 250

INTRODUCTION
Injuries to children’s feet, despite all the little bones and joints, are usually sim-
“The happiest
ple and easily managed. Most fractures are straightforward with no subtleties or
tricks and few are even displaced. On the other hand, a missed midfoot frac-
people seem to be
ture-dislocation could lead to disability. In many cases, the magnitude of the those who have no
soft tissue injury may be more significant than the fracture.
In contrast to the traditional presentation of many fracture texts that begin particular cause for
with the hindfoot, we will start the chapter by discussing the more common
phalangeal and metatarsal fractures, followed by the less common talar and cal- being happy except
caneal fractures.
that they are so”
PHALANGEAL FRACTURES —DEAN INGE
Modern culture provides a variety of opportunities for toe fractures ranging
from a television falling on a toe to kicking a sibling (Fig. 17-1). The pain is se-
vere, the x-rays may be uncertain, and the patient requires your care and atten-
tion even though the problem may seem small to you.

243
244
Foot
Figure 17-1. Longitudinal fracture of dis-
tal phalanx great toe was treated with a
hard-soled shoe.
“For toe fractures the choice
of immobilization methods
(tape vs. hard shoe vs. cast) is
often determined by the
patient and family’s
temperament and response
to pain”
Simple phalangeal fractures require protection to allow healing. This protec-
tion may range from simple taping, taping plus a hard-sole shoe (wooden-sole
style-“post-op” shoe) versus a well-molded short leg (below knee) cast. For toe
fractures the choice of immobilization methods (tape vs. hard shoe vs. cast) is
often determined by the patient and family’s temperament and the child’s re-
sponse to pain. For simple taping treatment, follow-up may not be required, be-
cause post-healing x-rays are rarely needed.
On occasion, the toe fracture is significantly angulated (especially Salter-
Harris II fracture—proximal phalanx) and requires reduction. The digital block
plus pencil as fulcrum reduction method used for fingers also works well for toe
fractures.
In cases requiring surgery, reduction can often be achieved by closed manip-
ulation with the help of a reduction clamp followed by percutaneous K-wire
fixation. Small, fine K-wires are used to stabilize the fracture in its reduced posi-
tion. If the fracture cannot be reduced by closed means, open reduction is indi-
cated followed by fixation with fine K-wires or a small screw. The open reduc-
tion may be associated with joint stiffness.
Growth arrest is occasionally seen as a late consequence after stubbing of the
great toe, likely due to an occult Salter-Harris V physeal injury. In other circum-
stances, a stubbed great toe may sustain an open Salter-Harris I fracture of the
distal phalanx with damage to the nail bed and matrix. Infection may follow
without adequate care. These fractures should be recognized as open injuries and
carefully cleaned and kept well-dressed, and the patient should be treated with
oral antibiotics.
Problem Fractures—Great Toe
Displaced, intra-articular fractures of the big toe proximal phalanx, a common
injury in soccer and other sports, are often undertreated. These fractures require
accurate reduction. All intra-articular fractures have a risk for nonunion and
this important joint is no exception. As in any intra-articular fracture, a gap of
!2 mm may allow cast treatment only (cast to tip of great toe, dorsal and plan-
tar, to optimize immobilization—non-weight-bearing for 3 weeks, then weight-
bearing—Fig. 17-2). Interim x-ray checks are required to rule out loss of re-
duction. Fractures within the gray zone of 2-3 mm of displacement may need a
fine-cut CT scan to make a final decision regarding operative treatment. With
significant displacement, internal fixation is required (Fig. 17-3).
At Injury After ORIF
Figure 17-3. Intra-articular fractures need
Figure 17-2. This Salter-Harris III frac- to be anatomically reduced to minimize the
ture is a common soccer injury that can be risk of arthritis. A step off or gap "2 mm
treated in a cast if minimally displaced. should not be accepted at any joint.
 Old nonunions often persist with symptoms and a relatively smooth longitu- 245
dinal line crossing the proximal phalanx epiphysis. A cast can be tried but inter- Metatarsal Fractures
nal fixation likely will be needed to achieve union. A similar smooth longitudi-
nal line crossing the epiphysis of the distal phalanx (so-called fissuring is
considered a normal anatomic variation.

METATARSAL FRACTURES
Current childhood culture that includes aggressive skateboarding, dirt-bike rac-
ing, and television-inspired jumps often from dizzying heights, makes foot frac-
tures common, especially metatarsal fractures.

Shaft and Neck Fractures

The often severe nature of these injuries (as well as the foot being naturally de-
pendent) often leads to marked swelling with metatarsal fractures. Compart-
ment syndrome can involve the interossei and short plantar muscles. X-rays
may need to include oblique views to clarify the injury (especially important if a
tarsal-metatarsal fracture-dislocation is suspected).
Most metatarsal fractures, even with moderate displacement can be treated
simply by immobilization in a short-leg walking cast for 3 to 6 weeks depend-
ing on the child’s age and activity level (Fig. 17-4). The cast is split widely for
the first week to allow for swelling. In cases with severe swelling, a well-padded
(bulky Jones) splint may be needed for the first week.

Multiple Fractures
Multiple, displaced, metatarsal fractures may require reduction depending on
the age of the patient and whether the first and fifth metatarsals are involved. A
fair amount of displacement of the middle metatarsals is acceptable as is angula-
tion of the metatarsal necks (often up to 45°) because significant remodeling
can be expected in younger children.
In the child nearing skeletal maturity, much less angulation can be accepted,
because abnormal weight bearing will result with little potential for adequate re-
modeling. Thus in the older age group, the foot should be aligned, not only to
prevent splayfoot deformity but also to prevent asymmetric loading of the
metatarsal heads (Fig. 17-5).
At Injury After ORIF
1 Year After Cast Treatment

At Injury

Figure 17-5. Multiple metatarsal frac-

Figure 17-4. Initial and 1-year follow-up
AP x-rays in a teenage boy with 2nd and 3rd
metatarsal neck fractures treated in a short
leg cast with toe plate. Remodeling of the
fractures has allowed normal function.
tures with displacement can be treated
with closed reduction and pinning
(metatarsal 2 and 3 in this patient) or ORIF
(1st metatarsal). This patient also had a
cuboid fracture that required ORIF.
246
Foot
After Closed Reduction
At Injury and Pinning
Figure 17-6. First and 5th metatarsal frac-
tures need to be reasonably well aligned to
maintain the borders of the foot.
“Unfortunately, this
distinction is clouded by the
fact that the apophysis can
be traumatically avulsed”
Normal Apophysis Avulsion Fracture
Figure 17-7. On the left, x-ray depicts a
normal apophyseal growth center at base
of 5th metatarsal with radiolucent line par-
allel to shaft. In contrast, the x-ray on the
right shows a transverse fracture at the
base of the 5th metatarsal.
In cases requiring reduction, manipulation can be attempted with traction
applied to the corresponding toes of the fractured metatarsals and countertrac-
tion applied to the distal tibia. Percutaneous K-wire fixation may be necessary if
the reduction is unstable. In this instance, K-wire fixation may also prevent a
nonunion from developing, which can result in a short toe and in asymmetric
metatarsal head position with painful metatarsalgia. K-wire fixation of the first
and fifth metatarsal fractures maintains metatarsal length and assists in preserv-
ing reduction of the other metatarsals.
Occasionally, open reduction is necessary for unreducible fractures. This is
performed through a dorsal longitudinal approach. The K-wire is passed
through the medullary canal of the distal fragment, exiting in a plantar direc-
tion after passing across the metatarsal head. The wire is pulled through distally
to the level of the fracture, and after reduction, the wire is drilled retrograde
into the proximal fragment and into the midfoot if necessary.
Compartment syndromes of the foot can occur with severe fractures and
must be recognized with proper monitoring and treatment (Silas et al.—Sug-
gested Readings).
First Metatarsal Fractures
Proximal fractures (Fig. 17-6) may damage the physis resulting in shortening of
the medial side of the foot. Johnson described a variation of the Lisfranc injury
(in children younger than the age of 10 years), which causes a fracture of the
proximal first metatarsal physis with associated medial cuneiform injury.
Crush injuries of the first metatarsal may affect its length. Length can be re-
stored by closed reduction and percutaneous pinning to adjacent metatarsals.
Fifth Metatarsal Base Fractures
Soccer, football, baseball, and basketball inversion injuries commonly produce
avulsion fractures of the base of the fifth metatarsal. The avulsion is thought to
occur because of the pull of the peroneus brevis or the tendinous portion of the
abductor digiti minimi.
The fracture is distinguished from the apophyseal growth center (os
vesalianum) by the direction of the radiolucent line. The long axis of the
apophysis is parallel with the shaft (a normal finding), whereas a true fracture
line is transverse (Fig. 17-7). The apophysis appears around age 8 and unites to
the shaft by age 12 years in girls and 15 in boys.
Unfortunately, this distinction is clouded by the fact that the apophysis can be
traumatically avulsed, often with little or no displacement and thus the x-ray may
seem normal (longitudinal line), yet the patient has severe pain and requires treat-
ment. In both true fractures and apophyseal separation, treatment includes a
short-leg weight-bearing cast worn for 3 to 6 weeks, depending on the child’s age.
Jones Fracture
Because of Robert Jones’ intricate description of his own fifth metatarsal injury,
fractures of the proximal diaphysis of this bone are known as “Jones fractures.”
It is important to differentiate this fracture from a fracture of the tuberosity, as
the two differ considerably in prognosis and management. Jones fractures are
much more likely to go on to nonunion and cause long-term difficulties. Meta-
physeal fractures on the other hand heal quickly and uneventfully.
The mechanism of injury of a Jones fracture is not thought to be an avulsion
but rather the result of vertical or mediolateral ground forces on the weight-
 Sir Robert Jones
1857–1933
Robert Jones is a name that keeps recurring in British orthopedics because he built up a school of
orthopedics, because he built up a system of organization for the care of orthopedic patients, and
because he made many contributions over the whole field.
When Robert was 16, he went from his home in London to live with his uncle Hugh Owen
Thomas in Liverpool, who sent him to medical school.Agnes Hunt interested him in children, and
from his small, informal beginning there grew the Robert Jones and Agnes Hunt Orthopedic Hospital
at Oswestry, serving most of the center of England and Wales.When World War II broke out, he
quickly ascended the military hierarchy and became Director General of Military Orthopedics.
Robert Jones made orthopedics a specialty.

bearing foot. Because the blood supply of the proximal diaphysis is limited Jones Fracture
compared to that of the tuberosity, healing will be delayed, especially in athletes
(Fig. 17-8). Non-weight-bearing immobilization is therefore recommended.
Repeat fractures or nonunion are usually treated with intramedullary screw fix-
ation with or without bone grafting. In athletes, regardless of age, there has
been a recent trend toward immediate intramedullary screw fixation.

Stress Fractures
Metatarsal shaft stress fractures are commonly referred to as “march fractures”
because of their high incidence in military recruits. Athletes frequently sustain
these fractures, but they also can occur after procedures to correct clubfoot, hal-
lux valgus, and hallux rigidus, in which the weight-bearing distribution to the
lesser metatarsal heads is affected. Repetitive microstresses cumulatively lead to
fatigue fractures of the bone.
Many patients with this injury present with foot pain but normal x-rays. If
there is a high degree of suspicion, a bone scan or MRI should be obtained to
Figure 17-8. Fractures at the metaphyseal
clarify the diagnosis. The second and third metatarsals are most commonly in- diaphyseal junction of the 5th metatarsal
volved. are at higher risk of nonunion.
Treatment involves activity restrictions and usually immobilization in a short
leg cast for 3 to 6 weeks. Subsequent x-rays will show the periosteal new bone
that typifies the fracture (Fig. 17-9).
Initial X-ray 3 Weeks Later
TARSOMETATARSAL INJURIES
(Lisfranc Injury)
The tarsometatarsal joints can be injured directly or indirectly with the indirect
method being by far the more common. Forces producing an indirect injury in-
clude violent abduction or forced plantarflexion of the forefoot, either alone or
in combination. Hardcastle and associates proposed an anatomic method of
classifying tarsometatarsal injuries (Table 17-1).
Although swelling of the midfoot is usual, there may be no obvious defor-
mity because spontaneous reduction of the injury to a near-anatomic position
commonly occurs. A fracture of the base of the second metatarsal should raise
suspicion of an associated tarsometatarsal dislocation. The combination of a A B
fracture of the cuboid with a fracture of the second metatarsal base also indi-
Figure 17-9. A) Early on, x-rays of pa-
cates a tarsometatarsal dislocation. tients with stress fractures often appear
Radiographic documentation of this injury is difficult and oblique views are normal. B) X-ray of same patient several
mandatory. Although stress views have been suggested, a CT study is more weeks later after immobilization in cast
commonly used. showing healing 2nd metatarsal stress frac-
ture.
247
248
Table 17-1 Lisfranc Injury Patterns
Foot
Type A
Incongruity of the entire joint
At Injury After ORIF
Figure 17-10. Initial and postoperative
AP radiograph of teenager with type C Lis-
franc injury treated with open reduction
and internal fixation.
Figure 17-11. AP x-ray of a child afebrile,
who presented with a limp after a fall. The
x-ray suggests a subtle compression frac-
ture of the cuboid (arrow). A three-phase
bone scan shows increased uptake at the
fracture site. After 2 weeks in a walking
cast he had no symptoms.
248
Type B Type C
Partial instability (medial or lateral) Divergent with partial or total instability
(rare)
Nondisplaced tarsometatarsal dislocations can be treated with elevation and
an initial compression dressing initially followed by a short leg cast to complete
4 to 6 weeks of immobilization. Displaced fractures require reduction. Manipu-
lative closed reduction is often successful, but supplemental Kirshner wire fixa-
tion is almost always added to ensure stability (Fig. 17-10). The key to reduc-
tion is to stabilize the second metatarsal base fracture.
A posterior splint is usually applied for the first week to allow for postopera-
tive swelling, with the child then placed in a short leg non-weight-bearing cast
to complete 4 to 6 weeks of immobilization. At the end of 4 weeks, the Kirsh-
ner wires are removed often through a window in the cast (less stressful for the
patient). Weight bearing in a walking cast or in a hard-sole shoe continues for
another 2 to 3 weeks.
MIDFOOT (LESSER TARSAL BONES)
FRACTURES (Navicular, Cuneiforms,
Cuboid)
Isolated fractures of the lesser tarsal bones are usually the result of direct trauma
such as an object falling from a height. More often, these fractures are seen in
association with a more severe injury to the foot.
A simple compression fracture of the cuboid bone due to a jumping injury is
actually more common than was traditionally thought (Fig. 17-11). Often diag-
Cuboid Compression Fracture
nosed as a sprain, very careful x-ray analysis will show a subtle buckle of the cor-
tex (early) or a radiodense healing line after several weeks.
Treatment of isolated nondisplaced fractures consists of immobilization in a
weight-bearing cast for approximately 3 weeks.
Bohler’s
angle
CALCANEAL FRACTURES
Children seldom fracture the os calcis, but when they do, most are caused by a
fall from a height. Schmidt and Weiner reported on compression fractures of
the spine in association with calcaneal fractures in children when the mecha-
nism involved a fall from a height. Lateral radiographs of the spine are therefore
recommended in this setting. Open fractures resulting from a lawn mower in- Figure 17-12. Lateral x-ray of the foot il-
jury are also relatively common in parts of North America where children par- lustrating landmarks used to measure
ticipate in lawn care activities. Bohler’s angle—Normal # 20°-40˚. This
angle will be decreased in compression
Sagittal plane calcaneus fractures are easily missed if axial (Harris) views of type calcaneus fractures.
the os calcis are not taken. On the lateral view, Bohler’s angle (angle formed by
a line parallel to the articular surfaces of the calcaneus with a line drawn along
Plain X-ray
the superior border of the tuberosity—Fig. 17-12) is measured. Depression of
the subtalar joint decreases this angle.
As in other complex fractures, a CT scan is often required for a clear under-
standing of the injury pattern. For intra-articular fractures, the CT scan clarifies
the degree of subtalar joint incongruity.
Most fractures of the calcaneus in children involve the tuberosity and heal
uneventfully. Nondisplaced fractures can be treated in short leg cast, which is
initially split widely to allow for swelling. At the end of a week, once the initial
swelling is decreased, the cast is overwrapped and weight bearing is allowed. CT image
The cast is discontinued once sufficient healing is present, usually after 4 to 6
weeks. With avulsions of the tuberosity or significant displacement, open re-
duction and internal fixation is necessary.
Given the remodeling potential of the talus and calcaneus in a growing child,
and the favorable results reported after non-operative management, most of
these fractures in children can be managed without surgery (Fig. 17-13). Treat-
ment involves non-weight-bearing immobilization for 6 weeks.
Figure 17-13. Minimally displaced frac-
In cases with severe intra-articular involvement and loss of Bohler’s angle,
tures of the calcaneus in young children
difficult decisions may be required. Some surgeons may elect conservative treat- can be treated with immobilization.
ment (cast only) even in relatively severe injuries because they are not certain
that the natural history would be improved on by an operation. Open reduc-
tion is appropriate for certain cases. Because of the rarity of such an injury in a
child, one should likely seek the help of a surgeon who has experience with
these injuries in adults.
Extra-articular fractures seem to do well regardless of treatment, with the
possible exception of fractures involving the anterior process. The anterior
process of the calcaneus is not well seen on radiographs until age 10 and varies
in shape. The distal portion of the fracture fragment articulates with the calca-
neocuboid joint. If severe articular displacement and joint depression are evi-
dent, open reduction is indicated.
Open fractures should be treated with standard irrigation, débridement, and
fixation. Lawn mower injuries are a common cause of open foot fractures (Fig.
17-14).

SUBTALAR DISLOCATION
Figure 17-14. This lawn mower injury
Subtalar dislocations are extremely rare in children and can be associated with with open fracture of the calcaneal tuberos-
talar neck fractures or other fractures around the foot and ankle. Reduction can ity was treated with irrigation, débridement
usually be accomplished by closed methods. and ORIF.
249
250
Foot
“Because so much of the
talus is articular, it has a
precarious blood supply with
few sites for blood vessel
entry”
Figure 17-15. Blood supply to the talus
is limited and can be interrupted by frac-
tures, resulting in AVN—especially of the
talar body.
At Injury
After ORIF
Figure 17-16. Initial and postoperative
lateral x-rays of patient with displaced
talar body fracture treated with open re-
duction and internal fixation through com-
bined medial and lateral approach.There is
a significant risk for osteonecrosis.
TALAR FRACTURES
Fractures of the talus are unusual in children. The talus, entirely articular and
saddle shaped, is divided into three parts—the neck, body, and head. Because
so much of the talus is articular, it has a precarious blood supply with few sites
for blood vessel entry. The arterial source enters the bone on the dorsum of
the talar neck in the sinus tarsi and medially deep to the deltoid ligament (Fig.
17-15).
The most common mechanism of injury is forced dorsiflexion of the foot.
AP, lateral, and oblique radiographs centered on the hindfoot should be taken.
If the nature and extent of the talus injury remain difficult to define by x-ray, a
CT scan is recommended.
Talar Neck
The majority of talar fractures are nondisplaced neck fractures, which can be
treated with immobilization for 6 to 8 weeks in a long leg cast with the knee
flexed to prevent weight bearing. At this time, the fracture is usually united, and
the child can be changed to a short leg walking cast for another 2 to 3 weeks.
Nondisplaced fractures of the talar neck are rarely associated with osteonecrosis.
However, more severe injuries can result in avascular necrosis (AVN) of the talar
dome due to vessel damage (Fig. 17-15).
The amount of acceptable displacement of talar neck fractures in children is
not well defined. Canale and Kelly considered a reduction with less than 5 mm
of displacement and less than 5° of malalignment on the AP view to be ade-
quate.
Minimally displaced fractures can usually be treated by closed reduction with
the foot in plantarflexion. Depending on the direction of instability the hindfoot
is either inverted or everted. With a stable reduction, the foot can be dorsiflexed
during immobilization. Otherwise, the foot is immobilized in plantarflexion for
6 to 8 weeks. If the reduction remains unstable despite plantarflexion of the foot,
fixation can be achieved by percutaneous K- wires. Patients with more displaced
fractures should have urgent reduction in the operating room.
If the ankle joint is disrupted because of displacement of the talar body, open
reduction is necessary. The posterior approach just lateral to the Achilles tendon
is preferred, if possible, because it avoids dissection around the neck with its
vulnerable blood supply. A minimal anterior exposure may be added if neces-
sary to obtain a satisfactory reduction.
The traditional open reduction has been performed through a dorsomedial
approach staying on the medial side of the extensor hallucis longus. Care must
be taken to avoid removing any soft tissue attachments from the bony frage-
ments. Two 4-mm canulated screws, a single larger screw, or multiple K-wires
can be used for fixation.
The child should be monitored monthly for the first 6 months to assess the
vascular status of the talus as most cases of osteonecrosis occur during this time
interval in children. In the absence of complications, talar neck fractures should
be followed for 1 to 2 years after injury.
Body
Displaced fractures through the body are rare and require open reduction and
internal fixation using a combination of approaches listed previously (Figure
17-16).
Lateral Wall 251
Puncture Wounds of the Foot and
Lateral wall fracture, probably reprensenting an osteochondral fragment avulsed Pseudomonas Osteomyelitis
by the anterior talofibular ligament, is rare and seldom recognized initially. The
mechanism of injury is dorsiflexion of the inverted foot. Persistent pain and
point tenderness just in front of the lateral malleolus should indicate the need “Patients with displaced
for oblique radiographs or a CT scan to show the small, loose body. Open re- fractures should have urgent
duction and internal fixation versus excision may be needed.
reduction in the operating
Os Trigonum room”
The os trigonum is a normal variant, which can sometimes be confused with a
fracture of the posterior process of the talus (Fig. 17-17). It is an accessory cen-
ter of ossification that appears around the age of 8 to 10 in girls and 11 to 13 in
boys. Unlike a fracture with sharp, jagged edges, the os trigonum appears
rounded and smooth. In rare cases, this center is injured and chronic movement
through the fibrous union attachment can cause symptoms (especially in ballet
dancers). The workup is difficult and, in rare cases, the os trigonum must be
surgically removed.

PUNCTURE WOUNDS OF THE FOOT

AND PSEUDOMONAS OSTEOMYELITIS Figure 17-17. Os trigonum is a normal
variant that may be mistaken for a fracture.
The smell of socks and shoes is due to Pseudomonas. Puncture wounds, as a re-
sult of a nail penetrating the shoe, can inoculate Pseudomonas and produce os-
teomyelitis (Fig. 17-18). Puncture wounds are common but this is rare—per-
haps 0.6% of puncture wounds will get a Pseudomonas abscess.
Pseudomonas infection becomes apparent a week or two after the puncture
because of increasing pain, swelling, and erythema. If the joint was punctured, a
septic arthritis may be produced. This is common at the metatarsophalangeal
joint. Radiographic changes may take 3 to 4 weeks to appear. A three-phase
bone scan or MRI can help make the diagnosis of osteomyelitis earlier.
Débridement of the area under general anesthetic is recommended. Antibi-
otic coverage should initially include a cephalosporin to cover for Staphylococcus
Aureus and an antipseudomonas drug such as gentamicin until the organism is
identified and the sensitivities are known. With late presentation, the joint and
physis may be permanently damaged by the infection, although chronic infec-
tion is rare.

Figure 17-18. Puncture wounds through a tennis shoe may lead to a Pseudomonas os-
teomyelitis.
Suggested Readings
Brunet JA. Calcaneal fractures in children.
Long-term results of treatment. J Bone
Joint Surg Br. 2000 Mar;82(2):211-6.
Buoncristiani AM, Manos RE, Mills WJ.
Plantar-flexion tarsometatarsal joint in-
juries in children. J Pediatr Orthop. 2001
May-Jun;21(3):324-7.
Dameron TB Jr: Fractures of the proximal
fifth metatarsal: Selecting the best treat-
ment option. J Am Acad Orth Surg
3:2:110, 1995.
D'Souza LG, Hynes DE, McManus F,
O'Brien TM, Stephens MM, Waide V.
The bicycle spoke injury: an avoidable
accident? Foot Ankle Int. 1996 Mar;
17(3):170-3.
Fitzgerald RH, Cowan JDE: Puncture
wounds of the foot. Orthop Clin North
Am 6:965, 1975.
252
Horowitz JH, Nichter LS, Kenney JG, Mor-
gan RF. Lawnmower injuries in children:
lower extremity reconstruction. J Trauma.
1985 Dec;25(12):1138-46.
Inokuchi S, Usami N, Hiraishi E,
Hashimoto T. Calcaneal fractures in chil-
dren. J Pediatr Orthop. 1998 Jul-Aug;
18(4):469-74.
Jensen I, Wester JU, Rasmussen F, et al:
Prognosis of fracture of the talus in chil-
dren: 21(7-34)-year follow-up of 14
cases. Acta Orthop Scand 1994;65:
398-400.
Kay RM, Tang CW. Pediatric foot fractures:
evaluation and treatment. J Am Acad Or-
thop Surg. 2001 Sep-Oct;9(5):308-19.
Laliotis N, Pennie BH, Carty H, et al: Tod-
dler’s fracture of the calcaneum. Injury
1993;24:169-170.
Maffulli N. Epiphyseal injuries of the proxi-
mal phalanx of the hallux. Clin J Sport
Med. 2001 Apr;11(2):121-3.
Mora S, Thordarson DB, Zionts LE,
Reynolds RA. Pediatric calcaneal frac-
tures. Foot Ankle Int. 2001 Jun;22(6):
471-7.
Schmidt TL, Weiner DS: Calcaneal fractures
in children: an evaluation of the nature of
the injury in 56 children. Clin Orthop
171:150, 1982.
Silas S, Hertzenberg J, Myerson M, Spon-
seller D. Compartment syndrome of the
foot in children. J Bone Joint Surg (Am)
77:356-361, 1995.
Wiley JJ. Tarso-metatarsal joint injuries in
children. J Pediatr Orthop. 1981;1(3):
255-60.
 18Spine
Bruce Gillingham m Jeffrey Cassidy m Dennis Wenger

• Radiographic Issues 256

• Cervical Spine Injuries 261
• Thoracic and Lumbar Fractures 263
• Spondylolisis and Spondylolisthesis 266
• Special Conditions 267

INTRODUCTION
Perhaps no injury to the developing skeleton incites as much anxiety in patient
“What people want
and doctor as trauma to the spine. Fortunately, pediatric spine fractures are rare
with only 5% of all spinal cord and vertebral column injuries affecting children
is not knowledge
age 16 and younger. Although uncommon, spine fractures in children can lead but certainty”
to chronic instability, deformity, neurologic sequelae, and posttraumatic steno-
sis. An extra measure of vigilance is called for in evaluating these injuries be- —BERTRAND
cause they can often be subtle or even absent on initial radiographs. Successful
treatment is based on knowledge of the radiographic, anatomic, and develop- RUSSELL
mental differences between the pediatric and adult spine.

Etiology
The location, pattern, and etiology of a child’s spine fracture is primarily de-
pendent on the patient’s age at the time of injury (Table 18-1). Birth trauma is
the major cause of spinal trauma in children younger than age 2. In patients be-
tween the ages of 3 and 8, the most frequent mechanisms of injury are falls,
motor vehicle accidents, and child abuse. Children older than 8 years are more
commonly injured in motor vehicle accidents, gunshot wounds, or sports in-
cluding swimming, diving, and surfing.
253
254
Spine
“Perhaps no injury to the
developing skeleton incites as
much anxiety in patient and
doctor as trauma to the
spine”
Figure 18-1. Klippel-Feil syndrome in-
cludes congenital fusion of two or more
cervical vertebrae.The AP view is less diag-
nostic in this case but does show spina bi-
fida occulta at the C7 level.
“The patterns and types of
spine injuries seen in
children reflect unique age-
related features of the
developing spine”
Table 18-1 Spine Fractures in Children (United States)
Age Most Common Causes
0–2 years Birth trauma
3–8 years Falls, MVA, child abuse
8 years and older MVA, sports (swimming, diving, surfing), gunshot wounds
MVA ! Motor vehicle accident.
Level of Injury
The majority of spinal column fractures in childhood occur in the thoraco-
lumbar spine. Cervical spine fractures in patients 8 years old or younger involve
the upper cervical spine (above C4). These most often include the occiput or
C1-C2 complex and are more likely to be fatal. Patients older than 8 more typ-
ically sustain injures below C4 with a much lower fatality rate.
Applied Anatomy
The patterns and types of spine injuries seen in children reflect unique age-
related features of the developing spine.
In children younger than 8 years of age, a number of anatomic factors place
the upper cervical spine at greater risk for injury. These include the relatively
large head size compared to the body, increased ligamentous laxity, relative strap
muscle weakness, and horizontal, shallow facet joints.
In addition, there is increased spinal column elasticity relative to older chil-
dren and adults. Injuring forces are dissipated over several adjacent motion seg-
ments exceeding the elasticity of the spinal cord itself.
Spinal cord injury without associated plain radiographic evidence of bony
trauma can occur resulting in the phenomenon known as spinal cord injury
without radiographic abnormality (SCIWORA).
Equally perplexing to the uninitiated are several normal developmental fea-
tures that can be misconstrued as evidence of injury to the spine. Lateral C-spine
views in children younger than age 2 years may be hard to interpret because the
anterior ring of the C1 vertebra has not yet ossified. Thus the dens-C1 interval
cannot be measured. The dento-central synchondrosis of C2, appearing as a lu-
cent line below the level of the body-dens interface, does not usually fuse until
about age 6 years and is often confused with an odontoid fracture.
Further complicating matters include congenital and genetic conditions that
have cervical spine manifestations. Klippel-Feil syndrome is characterized by
congenital fusion of two or more vertebrae (Fig. 18-1). Given the relative lack
of motion segments and resultant longer lever arm within the cervical spine,
these patients are felt to be at greater risk for fracture. A higher level of scrutiny
be given to these patients following trauma.
This is equally true of patients with trisomy 21 (Down’s syndrome) whose
inherent ligamentous laxity may result in symptomatic atlanto-axial instability
and cervical myelopathy. A careful instability assessment with lateral flexion-ex-
tension radiographs should be performed. Absence of the characteristic cervical
lordosis is seen in up to 14% of patients younger than age 8 and can be misin-
terpreted as representing injury-related muscle spasm.
Os odontoideum, thought to represent either a failure of fusion of the top of
the dens to the body of C2 or a nonunion of an occult fracture, can be difficult
to distinguish from an acute fracture. Further evaluation of these patients with
advanced imaging should be undertaken if this condition is identified on
screening trauma radiographs, as fixation or upper cervical fusion may be re- 255
quired. Introduction
After age 8, the spine begins to mature. The ligaments and facet capsules
strengthen, the facets become more vertically oriented, and the vertebral bodies
become more rectangular. By late childhood the patterns of spinal injury and
healing become similar to the adult.
The presence of the vertebral body ring apophysis also presents a challenge in
diagnosing spinal column fractures because the injuring force can traverse this car-
tilaginous growth plate, producing deformity that is unrecognizable on plain films.
In infancy, notching of the anterior and posterior vertebral bodies by vascu-
lar channels is common and is easily confused with a vertebral body fracture.
The anterior channel generally disappears by age 1, whereas the posterior notch
persists throughout life. Many issues make reading infant neck films problem-
atic (Figs. 18-2, 18-3)
Wedge-shaped vertebrae are common up to age 8 and are distinguished from
a compression fracture by similar appearance to their neighbors and absence of
associated soft tissue findings.

Initial Evaluation
Evaluation of the child with a suspected spinal fracture or spinal cord injury
(SCI) depends largely on the setting in which the child is seen. The vast major-
ity of pediatric spinal fractures and SCIs are due to motor vehicle accidents,
sports-related injuries, and falls.
The first orthopedic evaluation for most children will occur in the emer-
gency room. Given the increased participation of children in organized sports, a
physician may, on occasion, be required to perform an evaluation on the ath-
letic field and to coordinate the safe handling and transport of the potentially
spine-injured child to a medical facility.

Figure 18-2. Lateral C-spine view in a 3-

month-old child. The odontoid or dens
(black arrow) is identified, but there is no
bone noted anterior to it (white arrow).This
is because the anterior ring of C1 has not
yet ossified.
Figure 18-3. Moderate head tilt and rota-
tion seen in an AP view of the C-spine in an
infant with torticollis.
256 On the field, or at the scene of an accident, any children complaining of
Spine neck or back pain or transient/prolonged neurologic symptoms must be treated
as though they have a spinal injury. Once the airway, breathing, and circulation
have been secured, a brief secondary survey can be performed. Early immobi-
lization will help to prevent propagation of a SCI. Because the child’s head is
relatively large in relation to the body, a spine board with an occipital recess is
ideal for transport to ensure proper spinal alignment (Table 18-2). If one is un-
available, any rigid platform with blankets placed beneath the shoulders and
trunk will suffice. A pediatric cervical orthosis and sandbags or towels placed on
each side of the head will limit further motion. Until the cervical spine is
cleared, movement of the patient should only be performed with in-line trac-
tion using a logroll technique.
A brief history in the awake, alert, and cooperative child may be very helpful.
Any history of numbness, tingling, or brief paralysis or complaint of neck or
back pain should alert the physician to the possibility of a SCI. Physical exami-
nation begins with inspection of the body for signs of possible trauma to the
spine including obvious or subtle deformity, abrasions, edema, or bruising.
Inspection for abdominal wall ecchymosis suggestive of a lap belt injury are
important when evaluating a child involved in a motor vehicle accident. Pain or
step-off along the spinous processes should raise suspicion. Range of motion of
the spine should only be attempted in the awake and cooperative child in which
there is no suspicion of an unstable injury.

Figure 18-4. Loss of lordosis of the cervi-
cal spine may indicate occult injury.
RADIOGRAPHIC ISSUES
For minor spine trauma, often an AP and lateral view of the affected area will be
the only x-rays ordered. For more severe trauma, a more in-depth analysis is re-
quired.
Great care should be taken in the evaluation of children who are incapable of
verbal communication, who cannot cooperate with the clinical examination, or
who have other injuries that may divert their attention from concomitant neck
or back pain. These patients must be considered as having a spine injury until
proven otherwise. A diligent clinical and radiographic search for injury to the
axial spine is required.
The essential first study in these patients is a screening cross-table lateral x-
ray of the spine (Figs. 18-4, 18-5). This study, in addition to the AP pelvis and
chest x-rays, are considered standard in the evaluation of all trauma patients. It

Table 18-2 Emergency Transport of an Infant with Possible Spine Injury

(Hertzenberg, Hensinger et al. —see Suggested Readings)
Incorrect Correct

Straight board—Neck flexed Hole in board to accomodate head Trunk elevated on pad or blanket
Neck now straight Neck now straight
 257
Radiographic Issues

Figure 18-5. Normal alignment of the lateral cervical spine. 1 ! spinous process line, 2 !
spinolaminar line, 3 ! posterior vertebral body line, 4 ! anterior vertebral body line. Space
available for the cord is the distance between 2 and 3 at the level of C1.

is important to personally review this x-ray for technical adequacy, ensuring

that the top of the first thoracic vertebrae is visible. A systematic evaluation of
bony alignment (Fig. 18-5), soft tissue parameters, and relationships between
key landmarks is then performed (Table 18-3).
Any high-risk patient should have x-rays taken of all symptomatic areas or
have a complete spine series if the examiner is unable to focus the evaluation
clinically. In the obtunded patient, the spine should be cleared as early as possi-
ble to facilitate ICU services. A cervical orthosis and spine board precautions
should be maintained until definitive x-ray or clinical clearance is obtained (see
flow chart—Simple Algorithm for an Awake Patient).

Table 18-3 Normal Parameters of the Pediatric Cervical Spine

Parameter Normal Value
C1 facet-occipital condyle distance " 5 mm
Atlanto-dens interval " 4 mm
Pseudosubluxation of C2 on C3 " 4 mm
Pseudosubluxation of C3 on C4 " 3 mm
Retropharyngeal space " 8 mm (at C2)
Retrotracheal space " 14 mm (at C6, under age 15)
Torg ratio (canal to vertebral body) # 0.8
Space available for cord # 14 mm
Modified from Black BE. Spine Trauma—see Suggested Readings.
258
Spine Simple Algorithm for an Awake Patient with C-spine Injury
(neurologically intact)

258
Cervical Spine Imaging 259
Radiographic Issues
AP and lateral x-rays of the cervical spine will detect greater than 95% of frac-
tures. The open-mouth odontoid view may be a helpful adjunct to detect odon-
toid and atlas ring fractures (Fig. 18-6), although its usefulness and safety has
been questioned. As mentioned previously, the treating physician should be
aware of anatomic and physiologic variants unique to the developing cervical
spine in order to correctly interpret the images (Fig. 18-7).
If the child is alert and cooperative in the face of negative x-rays and com-
plains of neck pains, flexion/extension views may be used to identify ligamen-
tous injuries (see flow chart). In cases with a high index of suspicion, the physi-
cian can personally supervise this study with only active range of motion by the
patient assessed. No attempt to “assist” the patient to passively increase the A
range of motion should be attempted. It is frequently necessary to delay flexion-
extension films until the first outpatient visit when muscular soreness has

Common Methods to Immobilize the C-Spine

Soft Collar Aspen Collar
B

Figure 18-6. Odontoid views. A) Space

lateral to the odontoid is symmetric (nor-
mal). B) Assymetry of the space lateral to
the odontoid can indicate C1-C2 instabil-
ity. In this case, the child had only muscle
spasms.

“Just do something” More immoblization

Philidelphia Collar Minerva Type Brace

Figure 18-7. Normal findings on a pedi-

atric C-spine film that may be mistaken for
pathology.

More immobilization

Braces courtesy of Bluebird Orthotics

and Prosthetics—San Diego A serious brace
260
Spine

Figure 18-8. X-rays with the C-spine flexed are used to evaluate ligamentous instability.
Maintainence of a normal interval between the dens (odontoid) and the ring of C1, as well as
no change in vertebral body or posterior element alignment from C1-C7, suggests that the
ligaments are intact.

abated (Fig. 18-8). The patient is maintained in a Philadelphia type cervical or-
thosis for comfort and safety until then.
CT can help to identify occult fractures or to fully characterize fractures that
have been identified on plain films. MRI should be obtained to assess the de-
gree of cord injury in any child, with or without fracture, who has neurologic
complaints or symptoms, particularly those suspected of having SCIWORA.
MRI is also useful in assessing the extent of soft tissue damage in purely liga-
mentous and cartilaginous injuries.

Thoracic/Lumbar Spine Imaging

AP and lateral views of the thoracic and/or lumbar spine should be obtained in
the initial evaluation of any patient suspected of having a thoracic or lumbar
spine fracture. CT is the study of choice to evaluate bony architecture or to eval-
uate suspected injuries to the ring apophysis. As in the cervical spine, an MRI
should be obtained in the face of any neurologic signs or symptoms to assess the
degree of cord injury and is the imaging modality of choice for suspected carti-
laginous and ligamentous injuries.

TREATMENT
With a few exceptions that will be highlighted, the majority of fractures in the
pediatric spine can be treated non-operatively. Surgical stabilization should be
undertaken in unstable injuries or injuries associated with SCI.
Most cervical injuries are simple strains and require generic treatment (cervi-
cal collars are often used and come in a variety of types with varying capacity for
immobilization. A halo may be required for a very serious injury.
Antiinflammatories are also used and the patient is followed. Most are
greatly improved or asymptomatic within a few weeks. A few have more severe
injuries that will take weeks or even months to get well. Confusing the issue are
legal cases in which the patient, parents, and attorneys are monitoring the out-
come. Children often have a hard time recovering while these stressful events 261
are ongoing. Cervical Spine Injuries

CERVICAL SPINE INJURIES

Atlanto-occipital Dislocations
Atlanto-occipital dislocations occur almost exclusively in younger children and
are associated with the highest rates of closed head injury and mortality in pedi-
atric spine injuries (Fig. 18-9). These injuries were traditionally immediately
fatal but modern rapid rescue methods have led to a few survivors. Occipital
condyle fracture in association with this injury has been described and should
not be overlooked. If the child is neurologically intact, halo immobilization for
2-3 months will be successful in a majority of patients. For children with persist-
ent instability an occiput-to-C1 fusion may be necessary. Children with atlanto-
axial dislocation associated with SCI require fusion from occiput to C2.

Atlanto-axial (C1-C2) Injury

C1-C2 is the most common level of injury in the pediatric and adolescent spine
(Fig. 18-10). Either a fracture of the odontoid or atlanto-axial dislocation without
fracture may occur. Atlanto-axial dislocation without fracture is most likely to
occur in children younger than the age of 13. Fracture is more common in chil-
dren older than 13. Dislocations may be treated with halo immobilization for 3
months, but posterior C1-C2 fusion may be required for those with persistent in-
Figure 18-9. Atlanto-occipital disloca-
stability. tions occur almost exclusively in younger
children and are associated with the high-
est rates of closed head injury and mortal-
Atlas Fractures (C1 Ring) ity in pediatric spine injuries. In this case
Fractures in the “ring” of the C1 vertebra (atlas) are uncommon in children and (fatal), the skull is dissociated from C1
(large arrow) and C1 and C2 are dis-
are usually the result of a high-energy mechanism. For stable fractures, immobi- tracted (small arrow).
lization in a rigid cervical collar for 10-12 weeks allows healing. For more severe
injuries, or for families who do not have good internal discipline (for brace
wear), immobilization in a Minerva jacket or halo for 2-3 months will usually
result in complete healing. Immobilization up to 6 months is sometimes re-
quired, and surgery is rarely indicated.

Figure 18-10. This toddler suffered a flexion injury to the C-spine. The MRI study shows
posterior ligamentous injury (white arrow) at the C1-C2 level. She was treated with pro-
longed immobilization.
262
Spine

Grisel Syndrome
Trauma versus inflammation or in-
fection as the cause of sudden
change in use of the spine may con-
fuse the physician faced with cervi-
cal spine pain. Grisel was the first
to clarify the relationship between
acute torticollis and pharyngitis.
Grisel P. Enucleation des l’atlas
et torticollis nasopharyngien. Presse
Med 38:50-53, 1930.

Figure 18-11. Fixed rotary subluxation—C1 on C2. This 6 year old developed a fixed ro-
tary subluxation documented by CT scans.The problem eventually resolved with conserva-
tive treatment.

Atlanto-axial Rotary Subluxation

The onset of C1-2 rotary subluxation is often spontaneous and manifested by
pain, torticollis, and diminished range of motion. Often the result of only
minor trauma, Grisel (1930) first noted that the condition often is associated
with pharyngitis. In the current era, it often follows ear, nose, and throat proce-
dures and dental procedures in which the patient’s head was maintained in an
unusual position for a sustained period of time.
Radiographs, particularly the open-mouth odontoid view, will reveal a per-
sistent asymmetry of the odontoid in relation to the atlas. Dynamic CT studies
provide the best method for confirming the diagnosis (Fig. 18-11).
For minor cases, treatment consists of a brief period of immobilization in a
soft collar, rest, and analgesics. For more significant degrees of subluxation, a
brief period of head halter traction accompanied by systemic muscle relaxants
such as diazepam may be needed until reduction is achieved. For more severe or
longstanding cases in which a fixed subluxation has developed, halo traction or,
in extreme cases, surgical reduction with fusion may be needed.

Odontoid Fracture
Fractures of the odontoid process are rare in children and the incidence of asso-
ciated SCI is low. Treatment should consist of reduction and external immobi-
lization in a halo or Minerva jacket for 3 to 4 months. Surgical intervention is
rarely required and has been associated with a high rate of complications.

Hangman Fracture
Figure 18-12. Pseudosubluxation C2-C3. This morbid terminology follows the understanding that the cause of death in
Many patients have a normal slight forward successful hanging is not strangulation but instead traumatic fracture of C2
positioning of C2 on C3. with associated SCI (Fig. 18-12). The diagnosis of traumatic spondylolisthesis
 263
Thoracic and Lumbar Fractures

Figure 18-13. Halo application in an infant. Because the skull is soft, multiple pins are re-
quired and are tightened with a low torque (initially finger tightened)—then with a torque
wrench but not to exceed 4 to 5 inch-pounds of torque. (Mubarak et al.—see Suggested
Readings.)

of the axis (C2) may be confounded in children by persistence of a synchon-

droses until the age of 7.
Additionally, “pseudosubluxation” of C2 on C3 may be mistaken for injury.
Anterior subluxation of C2 on C3 of 2 mm or more implies pathologic subluxa-
tion and suggests fracture although a CT scan will be needed for confirmation.
Treatment should consist of reduction and application of a rigid cervical collar for
2-3 months. For more significant injuries or for poorly disciplined families, im-
mobilization in a halo device (Fig. 18-13) or a Minerva jacket may be necessary.

Middle to Lower Cervical Spine Injuries

Similar to fractures in the upper cervical spine, unstable ligamentous injuries in
the middle to lower cervical spine can be successfully treated with external im-
mobilization in either a halo device or Minerva jacket for 3 months. Injuries that
remain unstable after 3 months require a posterior fusion. For acute, unstable
fractures, as well as fractures associated with SCIs, posterior fusion is required.

THORACIC AND LUMBAR FRACTURES

Compression and Burst Fractures
In general, the inherent elasticity and mobility of the pediatric spine protects
children from compression and burst type fracture patterns. As the pediatric
spine matures and becomes more adultlike the pattern of injury in adolescents
and older children begins to mirror that seen in adults, with an increasing inci-
dence of compression and burst fractures. The patient’s relative maturity, degree
of deformity, instability, and the presence of SCI are all factors that must be
considered in planning treatment.
A working knowledge of the three-column concept of spinal stability devel-
oped by Francis Denis is essential to correctly identify and treat thoraco-lumbar Figure 18-14. Denis’ concept of spinal
spinal instability. He defined three categories of instability (Fig. 18-14, Table columns. If more then one column is dis-
18-4). rupted, stability is compromised.
 At Injury Post Reduction

Figure 18-15. L3 burst fracture in a motorcycle racer. Treated with partial corpectomy and anterior instrumentation L2 to L4.

Figure 18-16. Diagram of a child in a
seatbelt with a flexion injury that can pro-
duce a Chance fracture. Associated intra-
abdominal trauma is common.
Bed rest and immobilization are better tolerated in children than in adults.
Consequently, stable burst fractures and compression fractures with less than
10° of kyphosis and less than 50% loss of anterior column height can be treated
symptomatically. Most children do not require external immobilization and are
symptom free in 1-2 weeks but should refrain from sports for at least a month
to prevent re-injury. Children with more significant injuries or symptoms may
be treated with a brief period of bed rest followed by 4-6 weeks in a cast, a tho-
raco-lumbo-sacral orthosis (TLSO) for thoracic fractures or a Jewett hyperex-
tension orthosis for lumbar fractures.
With increasing skeletal maturity, the likelihood of improving sagittal align-
ment by subsequent vertebral growth decreases. For children beyond Risser
stage 2 with greater than 10° of kyphosis, the development of progressive defor-
mity in both the sagittal and coronal planes is more likely. For these patients,
posterior instrumented fusion should be considered. In addition, it has been
shown that children with compression fractures are more likely to develop evi-
dence of disc degeneration on MRI. The role of this phenomenon in guiding
treatment is unclear at this time.
As with injuries in the cervical spine, unstable fractures and fractures as-
sociated with SCI should be treated with a posterior instrumented fusion (Fig.
18-15). The role of decompression in neurologically compromised patients re-
mains controversial. Patients with incomplete return of neurological status or
degrading neurologic function are candidates for decompression. Evidence sug-
gests that early decompression may enhance neurologic recovery. In centers
with skilled spine surgeons, decompression and stabilization (even though clas-
sic predictors would not suggest neurologic recovery) should be considered.
“Miracle” recoveries or partial recoveries are occasionally seen in adults and
more often in children.

264
Table 18-4 Denis Classification of Spinal Column Instability
Spine
Type Instability Pattern Example Risk Treatment
1st degree Mechanical Severe compression fracture Progressive kyphosis Brace in extension
2nd degree Neurologic Ligamentously stable burst fracture Neurologic injury Operative stabilization
susceptible to collapse from axial load
3rd degree Mechanical and Unstable burst fracture, Progressive displacement Operative stabilization
neurological fracture-dislocation and neurologic injury decompression
Adapted from Denis F. Spinal instability as defined by the 3 column spine concept—see Suggested Readings.

264
Chance Fractures 265
Thoracic and Lumbar Fractures
Chance fractures, or Chance fracture equivalents, are flexion-distraction in-
juries. As in adults, they may be purely ligamentous, exclusively bony, or a com-
bination of both types (Table 18-5). Unique to children is the vertebral apoph-
ysis in the anterior column, through which the fracture frequently traverses.
The association between Chance fractures and lap belt injuries (Fig. 18-16) in
motor vehicle accidents has been well documented. Once associated intra-ab-
dominal injuries have been ruled out or treated, treatment of the spinal injury
may be planned.
As with compression fractures, stable injuries may be treated in a cast or
TLSO as long as an adequate reduction can be obtained and maintained. Purely
soft tissue injuries are less likely to respond to conservative treatment. These in-
juries as well as those associated with a SCI are best treated with a posterior
instrumented fusion from one level above to one level below the injury (Fig.
18-17).

Table 18-5 Classification of Chance Fractures

Type A Type B Type C Type D

Bony disruption of the
posterior column with
minimal extension into the
middle column
Avulsion of posterior elements
with facet joint disruption of
fracture and extension into
vertebral body apophysis
Posterior ligamentous
disruption with fracture
entering vertebra close to pars
interarticularis and extending
into middle column
Posterior ligamentous
disruption with fracture
traversing lamina and extending
into apophysis of adjacent
vertebral body

At Injury MRI CT Post Reduction

Figure 18-17. Chance fracture of the L2 vertebra in a teenager. Surgical reduction and stabilization was performed.
266 Table 18-6 Radiographic Classification of Lumbar Apophyseal Injury
Spine
Type Age Group Radiographic Findings
I 11–13 years Separation of the posterior vertebral rim. Arcuate fragment
without osseous defect
II 13–18 years Avulsion fracture of vertebral body, annular rim, and cartilage
III # 18 years Localized fracture posterior to end plate irregularity
IV # 18 years Defect spans entire length and breadth of posterior vertebral
margin between endplates
Adapted from Epstein N et al.—see Suggested Readings.

“Fractures of the vertebral Fractures of the Ring Apophysis

ring apophysis are unique to
the adolescent spine”
Fractures of the vertebral ring apophysis are unique to the adolescent spine.
Typically, a portion of the ring apophysis will be retropulsed into the spinal
canal along with herniated disc material. Four age-associated patterns have been
described (Table 18-6). Patients will typically present with back and or leg pain
after minor injury. Plain films and MRI are often inconclusive, and CT must be
used to confirm the diagnosis. Ring apophyseal fracture must be considered in
any adolescent presenting with symptoms of lumbar disc herniation. Conserva-
tive treatment may consist of rest, analgesics, and physical therapy and bracing
but is often ineffective in children. Surgical treatment includes decompression
of all herniated material including excision of the bony and cartilaginous frag-
ments and is felt to prevent healing of the lesion to the posterior vertebral body
with resultant spinal stenosis.

SPONDYLOLYSIS AND
SPONDYLOLISTHESIS
Sudden acute lumbar back pain in an athlete is a common presentation in an ER.
The “spondy” conditions are often the cause. A form of “fracture,” the condition
is really developmental. Spondylolysis and spondylolisthesis, conditions related to
weakness and then separation (stress fracture) of the pars interarticularis, most
commonly occurs at the L5 level (Fig. 18-18). Symptoms usually develop gradu-

Spondylolisis Spondylolisthesis

Figure 18-18. Spondy ! Spine. Lysis ! crack, break. Listhesis ! slip or slide. Acute lumbar back pain is a common reason for an ER visit.
The “spondy” conditions are a common culprit.
ally and the diagnosis is most common in vigorous young athletes (especially 267
gymnasts). In rare instances, a child can have an acute injury (or acute onset of Special Conditions
pain) and present as an emergency. Oblique views of the lumbosacral spine or a
CT scan can clarify the diagnosis. Treatment will not be described here.

SPECIAL CONDITIONS
Nonaccidental Trauma—Spine Injuries
Although child abuse is frequently thought of in terms of long bone injury, in-
jury to the axial skeleton and spinal cord is well described in this setting. SCI-
WORA can be seen as a component of the aptly named “shaken baby syn-
drome.” The infant’s large head-to-body ratio and relatively weak cervical
musculature likely predispose the defenseless child to this injury as a result of
repetitive hyperextension and flexion forces. Evidence of neurologic deficit
should be carefully sought in infants evaluated for nonaccidental trauma, as this
condition can be easily unappreciated in this age group.
A team approach is essential to thoroughly evaluate these patients in a com-
prehensive, systematic manner, with Child Protective Services notified immedi-
ately. A thorough orthopedic evaluation, including a skeletal survey that in-
cludes a lateral spine x-ray is essential in this setting. Consideration should also
be given to obtaining MRI images of the spinal cord at the time of intra-cranial
imaging if indicated by the clinical circumstances.
Thoraco-lumbar and lumbar injuries are most common in mid-childhood.
As with long bone fractures, spine fractures at different stages of healing are
highly specific for nonaccidental trauma. Fracture-dislocations and multiple
compression fractures may also be seen. Specific treatment is based on the in-
jury pattern present.

Spinal Cord Injury

The characteristic patterns of SCI in children are fundamentally different than
that seen in adults. Children sustain a disproportionately higher incidence of
upper cervical and thoracic spine injuries, a higher proportion of complete neu-
rologic injuries, and a much higher incidence of spinal cord injury without
plain film evidence of spinal column injury (SCIWORA). In addition, when an
injury to the spinal column occurs in association with SCI it is often difficult to
detect on plain x-ray. Most SCI in children younger than age 16 years results
from falls and motor vehicle accidents.
Following the initial trauma assessment and identification and resolution of
life-threatening conditions, a meticulous baseline neurologic evaluation is per-
formed and documented. Serial examinations should then be planned in order
to identify neurologic deterioration should it occur. In those patients capable of
understanding and communicating with the examiner, a history of transient
paresthesia, numbness, or paralysis should be sought, as this may be the only
clue to an occult SCI. Immobilization of the spinal column should be main-
tained until clinical and radiographic clearance is obtained.
The use of methylprednisolone should be considered if the patient arrives less
than 8 hours following injury, although the efficacy of this treatment is un-
proven in children younger than 13 years of age. GM-1 ganglioside, a glycolipid
found at high levels in the cell membranes of mammalian nervous system cells
with known neuroprotective and neuro-functional restorative properties, has
also demonstrated the potential to enhance functional recovery in SCI patients.
268
Spine
At Injury After Reduction
Figure 18-19. This 8-year-old boy pre-
sented with complete paralysis distal to
T12 due to fracture dislocation. He was
emergently reduced and stabilized and was
walking (with Fott orthosis) by 4 months.
It is best to err on the side of overtreat-
ment (surgical reduction) in children who
have great potential for recovery from
spinal cord injury.
.
The prognosis for children with a SCI is better for incomplete lesions, although
up to 20% of patients with a complete SCI experience significant recovery.
Three patterns of MRI signal in acute SCI have been described (Table 18-7).
In general, laminectomy alone should be avoided as this contributes to in-
creased instability with the subsequent development of localized kyphosis.
Laminectomy, cord decompression, and instrumented fusion can be considered
in cases with potential for neurologic recovery (Fig. 18-19).
Children who are preadolescents at the time of injury are at significant risk
for developing scoliosis following SCI, irrespective of the level of neurologic in-
jury, and are more likely to develop a severe scoliosis (Fig. 18-20). The presence
of spasticity is also a significant risk factor. The development of sagittal plane
deformity, especially lumbar kyphosis, is also common. Initial treatment should
consist of bracing and fabrication of a wheel chair seating system. The primary
goal of treatment is maintenance of sitting balance in order to prevent decubi-
tus ulcers and to preserve independent upper extremity use. Vigilant skin care is
essential to avoid pressure sores from the brace. Instrumentation and fusion are
often needed but ideally should be delayed until the child is mature enough to
allow for posterior segmental instrumentation alone (no longer at risk for post-
fusion progressive deformity due to the crank-shaft phenomenon.
Late neurologic deterioration has been reported in children who sustain a
SCI. Posttraumatic syrinx should be searched for with an MRI and, if present,
surgically corrected.
Spinal Cord Injury Without
Radiographic Abnormality
As originally described, the syndrome of SCIWORA is diagnosed in patients

with objective findings of myelopathy following trauma without evidence of

“The mechanism of spinal
cord injury presumably
occurs due to the inherent
immaturity and elasticity of
the spinal column relative to
the relatively fixed spinal
cord”
skeletal injury or subluxation on plain films, tomography, or myelography. The
syndrome was described prior to the use of MRI for diagnosis.
The mechanism of SCI presumably occurs due to the inherent immaturity
and elasticity of the spinal column relative to the relatively fixed spinal cord.
Significant but self-reducing intersegmental displacements of the spine due to
flexion, extension, or distraction forces cause SCI without associated vertebral
column disruption.
The condition is most common in children younger than 8 years of age.
These younger patients sustain more serious neurologic damage and suffer a
larger number of upper cervical cord lesions than children over the age of eight.
Up to half of the patients have delayed onset of paralysis, occurring as long as 4
days after injury. Of particular importance to the initial treating physician,

Table 18-7 MRI Patterns on T2 Weighted Images of Acute

Spinal Cord Injuries
Type Findings
I Decreased signal due to intraspinal hemorrhage
II Bright signal due to spinal cord edema
III Mixed signal: central hypointensity and peripheral hyperintensity due to contusion

Adapted from Bondurant FJ et al.—see Suggested Readings.

most of these children experienced transient paresthesia, numbness, or subjec- 269
tive paralysis at the time of injury. Occult instability with subsequent repetitive Suggested Readings
insults is one possible explanation for this phenomenon. Careful evaluation is
therefore critical in this setting to identify the underlying cord injury and
source of instability and to provide appropriate spinal stabilization to avoid pre-
ventable progression.
Further evidence for occult instability as a cause of delayed SCIWORA is the
phenomenon of recurrent injury. In one series, a trivial injury after an initial mild
SCIWORA resulted in a second episode of the condition several weeks later.
Radiographic evaluation includes initial plain films and an MRI. The MRI,
which allows assessment for occult ligamentous and disc injury and the status of
the spinal cord, has served to invalidate the SCIWORA terminology.
Clinically, the most reliable predictor of neurologic outcome is the initial
neurologic status. An initial severe neural injury is almost always associated with
a poor prognosis, whereas an initially mild to moderate injury is compatible
with good recovery. MRI findings are also highly correlated with prognosis. A
poor outcome is predictable if there is evidence of cord transection and major
hemorrhage, a moderate to good recovery is observed when minor hemorrhage Figure 18-20. Progressive scoliosis has
or edema only is present, and a complete recovery occurs in those patients with- been reported in children who sustain a
out abnormal cord signal. spinal cord injury.This child went on to re-
quire anterior/posterior spinal fusion.
The orthopedist’s role is to rule out occult fractures and subluxation requir-
ing surgical fusion, identifying patients likely to have delayed deterioration and
preventing recurrent cord trauma by initiating and rigidly enforcing a strict
neck immobilization program. It is recommended that a well-fitted custom cer-
vical orthosis that is difficult for the child to remove by him/herself be worn for
up to 12 weeks in patients who have sustained a mild to moderate form of this
injury. These patients are inclined to discontinue bracing and attempt to return
to their usual activities prior to complete healing. They are therefore at greatest
risk for recurrent injury. Late instability should be ruled out with dynamic cer-
vical spine x-rays prior to clearing a patient for return to regular activities, espe-
cially sports.

CONCLUSION
A thorough knowledge of the developmental characteristics of the pediatric
spine will greatly assist the treating physician. An understanding of the differ-
ences between the immature spine and that of the adult is fundamental to cor-
rectly diagnosing and treating pediatric spinal trauma. Fortunately, childhood
spinal trauma is rare and good outcomes are the rule in these resilient patients.
The views expressed in this chapter are those of the authors and do not re-
flect the official policy or position of the Department of the Navy, Department
of Defense, or the United States Government.

Suggested Reading
Bondurant, F.J.; Cotler, H.B.; Kulkarni,
M.V.; McArdle, C.B.; and Harris, J.H.:
Acute Spinal Imaging. Spine, 15:161-
168, 1990.
Brown, R.L.; Brunn, M.A.; and Garcia, V.F.:
Cervical spine injuries in children: a re-
view of 103 patients treated consecutively
at a level 1 pediatric trauma center. J Pe-
diatric Surg, 36(8): 1107-14, 2001.
Cattell, H.S.; and Filtzer, D.L.: Pseudosub-
luxation and other normal variations in
the cervical spine in children. J Bone
Joint Surg, 47:1295-1309, 1965.
Copley, L.A.; and Dormans, J.P.: Cervical
spine disorders in infants and children. J
Am Acad Orthop Surg, 6: 204-214, 1998.
Cullen, J.C.: Spinal Lesions in Battered Ba-
bies. J Bone Joint Surg, 57-B:364-366,
1975.
Dearolf, W.W.; Betz, R.R.; Vogel, L.C.;
Levin, J.; Clancy, M.; and Steel, H.H.:
Scoliosis in Pediatric Spinal Cord—In-
jured patients. J Pediatric Orthop, 10:
214-218, 1990.
Denis, F.: Spinal Instability as Defined by the
Three-column Spine Concept in Acute
Spinal Trauma. Clin Orthop, 189: 65-76,
1984.
Grabb, P.A.; and Pang, D.: Magnetic Reso-
nance Imaging in the Evaluation of
Spinal Cord Injury without Radiographic
Abnormality in Children. Neurosurgery,
35: 406-414, 1994.
Herzenberg J, Hensinger R, Dedrick D,
Phillips W. Emergency transport and po-
sitioning of young children who have an
injury of the cervical spine: the standard
backboard may be hazardous. J Bone
Joint Surg 1989;71:15-22.
Lalonde, F.; Letts, M.; Yang J.P.; and
Thomas, K.: Analysis of burst fractures of
the spine in adolescents. Am J Orthop,
30(2): 115-21, 2001.
270
Mubarak SJ, Camp JF, Vuletich W, Wenger
DR, Garfin SR. Technique: Halo applica-
tion in the infant. J Pediatric Orthop,
9:612-614.
Odent, T.; Langlais, J.; Glorion, C.; Kassas,
B.; et al.: Fractures of the odontoid
process: a report of 15 cases in children
younger than 6 years. J Pediatr Orthop,
19(1): 51-4, 1999.
Reid, A.B.; Letts, R.M.; and Black, G.B.: Pe-
diatric Chance fractures: association with
intra-abdominal injuries and seatbelt use.
J Trauma, 30(4): 384-91, 1990.
Takata K, Inoue S-I, Takahashi K, Ohtsuka
Y. Fracture of the Posterior Margin of a
Lumbar Vertebral Body. J Bone Joint
Surg 1988;70(4):589-594.
 Fractures in Special
19
Circumstances
(Vascular-Compartment Problems,
Nonaccidental Trauma, Pathologic Fractures)
Mercer Rang m Dennis Wenger m Scott Mubarak

• Fractures with Vascular Injuries 271

• Compartment Syndromes 278
• Nonaccidental Trauma 280
• Pathologic Fractures 285

VASCULAR AND COMPARTMENT

PROBLEMS “Every great
On the battlefield, arterial injuries are transported, and the decision to expose mistake has a
the artery is already partly made. The amputation rate is only 13% because of
prompt expert repair. For closed fractures with arterial damage, the amputation halfway moment, a
rate is up to 50% because of late diagnosis.
In fractures with arterial injury, the maximal permissible interval between in- split second when it
jury and repair is about 6-8 hours, depending on the degree of arterial occlu-
sion, the state of the collaterals, and shock. These 6-8 hours may pass quickly can be recalled and
while the patient is given narcotics and a doctor is found to split the cast. The
doctor always realizes there is trouble but seems unable to act immediately and
perhaps remedied”
decisively, hoping that the situation will miraculously improve.
Slowly, the doctor comes to appreciate that hope is not enough and calls for
—PEARL BUCK
an arteriogram or transfers the case to another hospital. Every minute should

271
272
Fractures in Special Circumstances
“Unfortunately, in the
emergency room, a child
with a fracture with
ischemia is not startlingly
different from a child with a
simple fracture”
count, because invisible changes are taking place in the muscles and nerves of
the limb. Yet in almost all the patients we have cared for, hours have been frit-
tered away. Successful care comes from a high index of suspicion and early arte-
rial repair. Successful care produces a normal limb; delay produces a Volkmann’s
contracture or gangrenous limb.
Physical Signs
Unfortunately, in the emergency room, a child with a fracture with ischemia is
not startlingly different from a child with a simple fracture. A crying child, with
a limb swathed in splints and bandage, and surrounded by distraught relatives,
is not easily viewed with cool, clinical detachment. A quick squeeze of a pro-
truding digit or nail bed for capillary filling is often considered sufficient to
demonstrate an intact circulation. Demonstrate the fallacy of this sign next
time you operate. Inflate the tourniquet before the limb is exsanguinated.
Squeeze the digit: capillary return is still present. This test only indicates that
blood is present in the limb and not that it is circulating.
In recent years, the guesswork has been taking from these problems by direct
measurement of compartment tissue pressure and by the use of Doppler pulse
meters.
The Three Faces of Arterial Occlusion
If occlusion is not recognized on admission, there is usually a considerable delay
before anyone notices it. A child’s ischemic pain may be borne stoically by the
staff and attributed to fracture pain or be clouded by opiate. Pulses are hidden
by a cast or traction so that observation is difficult. Remember that a splinted
limb should be relatively painless. Pain after reduction should be attributed to
ischemia until proven otherwise. A special trap is painless ischemia in a child
with a nerve palsy.
Complete Arterial Occlusion
The pulse is absent, the veins are empty, and in the course of an hour or two the
limb becomes white and cold. Failure of nerve conduction produces glove and
stocking anesthesia and paralysis. After a few more hours, rigor mortis results in
the muscles shortening, and attempts to overcome this are painful. Pain is ex-
treme. Later, the skin becomes marbled, and gangrene follows.
ISCHEMIC MUSCULAR PARALYSES
AND CONTRACTURES
Richard Volkmann, 1881
(Halle, Saxony, Germany)
“For many years I have been drawing attention to the fact that the paralyses and con-
tractures of the limbs which sometimes follow bandages applied too tightly, do not arise,
as was assumed, through paralysis of the nerves by pressure, but through wholesale and
swift disintegration of the contractile substance and the resultant reaction and regenera-
tion. The paralysis and contracture should be understood to have their origin in the
muscle.”
 273
Vascular and Compartment Problems

Figure 19-1. Volkmann’s ischemia. A) Nor-
mally the pressure in the brachial artery is
120 torr. Muscle is perfused at a pressure of
30 torr. B) Muscle ischemia. If the pressure
within the muscle compartment is raised
about 30 torr, muscle will not be perfused,
but the radial pulse is not necessarily oc-
cluded.
Figure 19-2. Compartment ischemia may
be due to arterial injury or to increased
compartment pressure.
Figure 19-3. Compensated occlusion.
Anastomotic channels maintain perfusion
at low pressure and sufficient to sustain
the tissue but insufficient to produce a
pulse at the wrist.The pulsations have been
abolished, but the flow remains. If an
eponym had been attached to this condi-
tion it would be diagnosed infrequently.

Incomplete Occlusion—Compartment Ischemia

Ischemia of muscle, called Volkmann’s ischemia (Fig. 19-1), is compatible with
an intact pulse and adequate peripheral circulation. The first signs are pain in
the muscle and pain on stretching the muscle. For this reason, we do not give
strong analgesics to children with fractures that have a reputation for vascular
problems. Compartment ischemia may be a sequel to an arterial injury (Holden
Type I) or to direct compartment injury (Holden Type II) (Fig. 19-2). Fre-
quently, there is sufficient arterial flow to maintain a pulse and distal circula-
tion, but the muscles and nerves become hypoxic and damaged. The outcome
of muscular ischemia is a Volkmann’s contracture. Compartment syndromes
will be described in more detail later.

Compensated Occlusion
This is most often seen in the child with a supracondylar fracture who has an
adequate distal circulation but no pulse (Fig. 19-3). The extremity may be a lit-
tle cool, but there are no signs of nerve or muscle ischemia. Despite occlusion of
the major artery, the collaterals maintain an adequate circulation. The best
treatment is immediate reduction. Apart from worrying and ordering an hourly
check on sensation and movement, there is nothing special to do. A Doppler
can be used to detect a faint pulse. Arteriography and exploration are meddle-
some. Within a few weeks the pulse returns, and we have yet to see a child with
claudication in this circumstance.
Figure 19-4. In the hour that followed
this injury, the leg became cold, white,
Sites of Fracture Associated with Vascular Damage anesthetic, and weak.The pulse was absent.
Although any fracture carries the hazard of vascular damage, the problem is After the fracture was reduced under gen-
eral anesthesia, the veins became full and
most likely in supracondylar fractures, elbow dislocations, fractures of the shaft the foot warm and pink. The pulse did not
of the femur, especially the distal one-third (Fig. 19-4), dislocation of the knee, return for several weeks. The femoral ar-
fractures of the proximal tibia physis, grossly displaced fractures of the ankle tery passes through the adductor opening
and talus, and midtarsal dislocations. at this site, where it is liable to injury.
274
Fractures in Special Circumstances
Figure 19-5. Mycotic aneurysm of pro-
fundus femoris. This 7-year-old girl was hit
by a truck. She sustained a fracture of the
femur (treated by 90-90 traction) and a se-
vere head injury, which resulted in her
being unconscious for a month. During this
time she was pyrexial at times and then de-
veloped multiple staphylococcal abscesses,
which required drainage. The mycotic
aneurysm attracted attention because of
swelling and repeated hemorrhages. Em-
bolization failed and the vessel was tied off.
Infection is a risk in multiple injuries be-
cause of poor nutrition and a plethora of
needles and tubes. Antibiotics are wise. PF,
profunda femoris; MA, mycotic aneurysm;
SF, superficial femoral artery.
The Nature of the Arterial Lesion
The incidence of arterial damage, as distinct from ischemia, in fractures is not
known.
Lesions in Discontinuity. There is completely transsection of the vessel.
Lesions in Continuity: Intimal Lesions. Intimal tears and contusions can only
be diagnosed with confidence by arteriotomy. The distal part of the vessel is
empty and stringlike. The condition is indistinguishable from spasm until the
intima is inspected.
Spasm. Traction has been shown experimentally to produce spasm. Application
of this observation has reduced the incidence of Volkmann’s ischemia in frac-
tures of the femoral shaft. However, in the past, the importance of “temporary
spasm” has been greatly overplayed at the cost of many limbs.
Compression. The most common causes of ischemia are undoubtedly tight
casts and deformity at the fracture site. Release the cast or align the limb, and
the circulation comes bounding back. Kinking and stretching of vessels has
been convincingly demonstrated after high tibial osteotomy.
Thrombosis. Prolonged occlusion owing to any cause will produce propagating
thrombosis.
Aneurysm. After a few days or weeks, the site of the fracture becomes painful,
red, swollen, and warm—like an infection—but when it is drained, there is a
gush of blood. The aneurysm may be caused by a partial tear of the artery at the
time of fracture; by the end of a pin, drill, or screw; or by a mycotic infection.
Small vessels may be tied off, but major vessels require a graft (Fig. 19-5).
Whenever you embark on releasing a hematoma, bear in mind that it may be a
false aneurysm. Listen for a bruit; consider an arteriogram. Check on the where-
abouts of your vascular surgeon before you start, just in case you will need help.
Management
Prevention
Traction, tight casts, excessive flexion of a swollen elbow, and hypotension all
produce ischemia in the absence of an arterial injury at the time of fracture. Be
vigilant, be quick, and be decisive. If you are lucky, removing bandages, bivalv-
ing the cast, and placing the limb in a dependent position may be enough to
improve circulation. If you are the resident, get on and do this; don’t call your
chief first, however precious the patient or the reduction.
Treatment of Limb Ischemia
If the circulation does not improve rapidly, you must make preparations to take
the child to the operating room immediately. As soon as diagnosis of ischemia is
reached, it is obviously a matter of extreme urgency, and you must not be put
off by any other service commitments or by anesthetists telling you that the
child has a full stomach. You should carry out surgery with the help of a vascu-
lar surgeon. However, in civilian practice, vascular surgeons do not have much
experience with the problem, and you cannot look to him or her to make all the
decisions. His or her greatest experience is in the treatment of vascular disease
in the elderly. The new group of microvascular surgeons may be your best ally.
Treatment Steps—Limb Ischemia
Arteriography. Arteriography is only of value if it can be carried out immedi-
ately: do not waste time rounding up staff. Arteriography always takes at least
an hour, whatever you are told, and in most cases this time could be better 275
spent relieving ischemia. It will demonstrate the site of occlusion, although it Vascular and Compartment Problems
will probably not disclose the type of lesion. The site of occlusion is usually op-
posite the fracture site. In one case, we suspected that the cause of ischemia may
have been tight bandaging; however, the arteriogram showed an intimal tear
opposite the fracture site.
Jim, aged 8, went down the hill on his friend’s bike so quickly that he was
unable to use the brakes on the handlebars and hit a truck, fracturing the left
femur. The circulation was unremarkable and he was placed in traction. The
following morning the leg was found to be white, anesthetic, and cold. An arte-
riogram showed obstruction of the superficial femoral artery (Fig. 19-6A). At a
later phase, the distal part of the artery filled slowly through collaterals (Fig. 19-
6B). The appearances indicated a block in the femoral artery with a distal com- “Ideally arterial damage
partment syndrome. should be recognized early
A femoral arteriotomy in the groin was carried out; Fogarty catheters were
passed the popliteal artery, and the clot was removed. Subcutaneous fasciotomy and repaired before
of three compartments of the leg was carried out. The skin became warm and irreversible complications
pink, but the pulse did not return.
Thirty-six hours later the circulation deteriorated and the leg looked like
occur”
white marble. It looked like the end. Another arteriogram (Fig. 19-6C) showed
an intimal tear at the fracture site and a block at the popliteal trifurcation (Fig.
19-6D). The leg was laid open through a Henry approach from groin to ankle.
After excision of the damaged section of the femoral artery, Fogarty catheters
were passed under vision to the ankle through the anterior and posterior tibial
arteries.

Expectations of Arterial Repair for Complete Ischemia

n
276
Fractures in Special Circumstances

A B

C D
Figure 19-6. A) Initial arteriogram made 15 hours after injury shows a complete block in the superficial
femoral artery. B) At a later phase, the superficial femoral artery fills slowly through collateral arteries. C) A
second arteriogram shows an intimal tear at the site of the arrow. D) Ischemia is due to a clot at the
popliteal trifurcation.
 The artery was anastomosed. All four compartments were decompressed (re- 277
vealing the inadequacy of subcutaneous fasciotomies). The skin was left open. Vascular and Compartment Problems
The circulation was no better. The boy began a series of dives in the hyperbaric
chamber and heparin was administered. After each dive, the color of the foot
improved.
The back of the leg was closed with skin grafts at 5 days. The fracture was
managed in a hip spica throughout because it was longitudinally stable. At 8
weeks the fracture was united and the cast was removed.
Six months after injury Jim had anesthesia from mid calf downwards and
about 30° of equinus. A year later sensation had returned but paresthesias were
a problem. A posterior release was performed and neurolysis of the posterior
tibial nerve. The paresthesias disappeared. He now walks normal distances but
with a marked limp, because most of the muscle below the knee has been de-
stroyed.
This is a typical story. Ideally, arterial damage should be recognized early and
repaired before irreversible complications occur.
Treatment of the Arterial Lesion. Direct inspection is the only certain way to
determine the nature of the lesion. For this reason, we expose the vessel widely
through one of Henry’s extensile exposures. The effectiveness of repair can be
judged, the extent of muscle damage can be discerned, and wide fasciotomy
may be carried out.
Lesions in Continuity. When the artery is constricted at the level of the frac-
ture, an intimal tear or contusion is most likely. In most cases, a vascular, neu-
rovascular, or plastic surgeon (with vessel repair training) will be doing the pro-
cedure with you. A segment of artery can be excised. The proximal end is
flushed out. The distal part is dilated and cleared of thrombus with a Fogarty
catheter and end-to-end suture undertaken if this can be done without tension;
otherwise, a reversed saphenous graft is inserted.

Lesions in Discontinuity
Lesions in Discontinuity are Repaired or Grafted.
Fasciotomy. Subcutaneous fasciotomy is quick and easy. It leaves little scar but
does not decompress the deep flexor compartments (Fig. 19-7). For this reason,
open fasciotomy is mandatory. In the calf, all four compartments must be
opened—anterior, peroneal, superficial, and deep posterior. In the arm, the
deep flexors and extensors require decompression.
Do Not Excise Any Muscle at This Time. It is impossible to distinguish the
sick from the dead. After arterial repair and fasciotomy, distal pulses should be-
come palpable and the veins should fill. The skin can never be closed after fas-
ciotomy, because the muscle has swelled. Cover the extensive wound with a pe-
troleum gauze dressing. Figure 19-7. This girl fell out of a tree.
Care of the Fracture. Is internal fixation the ideal method? The Vietnam experi- She almost died during the next 12 hours
ence suggested that it might add to morbidity because of infection and because of hypotension from a ruptured
spleen and a hemothorax. The fractured
nonunion. Our experience is limited, but for children who have not been in-
femur was placed in skin traction. The
jured on the battlefield we favor internal fixation whenever possible, because combination of muscle hypoxia owing to
traction may pull the anastomosis apart. A cast, which prevents examination of hypotension and somewhat tight bandaging
the entire limb, is contraindicated. External fixation works well and can be a produced a white, anesthetic leg. Arteri-
good choice. ogram shows no damage at the fracture
site but complete vascular occlusion
Complications. Because thrombosis affects up to 20% of repairs, the circula- caused by compartment compression. All
tion must be closely watched postoperatively. If there are signs of failure, the compartments were opened, and the ar-
vessel will need to be explored once again and the thrombus removed. teries were dilated with Fogarty catheters.
278
Fractures in Special Circumstances
“Do not write inspired
opinions about the quality of
prior care. If you do, you
will usually be wrong, and
certainly damage not only to
your colleagues’ reputation
but also your own”
Figure 19-8. Mechanisms of compart-
ment hypertension.
“With a suspected
compartment syndrome, we
prefer to have the help of the
anesthesia department who
routinely monitors arterial
and venous pressures”
Note-Keeping and Public Relations. Parents of children in whom ischemia is
noticed late usually believes that this catastrophe is somebody’s fault, and often
they are right. These cases usually go to litigation. Keep scrupulous notes; every
time you see the child, record your findings and note the time. Put down every-
thing; nothing is too insignificant. In all probability, you will rely on these notes
in court. You or your colleague will need all the help that only pages and pages
of notes will provide.
Request Your Colleagues’ Advice, As Needed. Not only may this be helpful,
but their written notes may be useful as well. If the case is referred to you, you
should keep in touch with the original doctor. Do not jump to the conclusion
that it is all his or her fault. Do not write inspired opinions about the quality of
prior care. If you do, you will usually be wrong, and certainly damage not only
to your colleagues’ reputation but also your own.
The Aftermath. In a few days, you will know whether a normal limb may be
expected or whether amputation or reconstruction will be required. The reward
of early repair will be a normal limb. Wet gangrene usually requires early ampu-
tation and secondary suture. In children, it is worth skin grafting a stump in
order to preserve length, particularly if it allows you to save the knee joint.
COMPARTMENT SYNDROMES
A rise in the pressure within a closed compartment may tamponade the muscles
and nerves so that they become ischemic. Muscles are normally perfused by
blood at a pressure of about 30 torr in a compartment with a tissue pressure of
3 torr to 4 torr. If the compartment
.
pressure exceeds 30 torr, the muscle will re-
ceive no blood, but the main arteries will not be compressed, the pulse will get
through (Fig. 19-8).
In everyday life, compartment pressure often exceeds 30 torr for a few min-
utes at a time. When making a fist, the muscle becomes hard, the pressure rises,
and the muscle loses its circulation for a time.
You may have noticed the effects when applying a cast on a leg. Have you no-
ticed how your assistant, who is grasping the toes, always drops the leg just be-
fore you have finished? This is because your assistant’s forearm muscles are is-
chemic all the time he or she grips; when the limit is reached, the leg is dropped.
The science of compartment syndromes has been much advanced by experi-
mental models. The anterior compartment of a dog’s leg can be injected with
blood to raise the pressure. Studies of nerve and muscle show that irreversible
changes begin after 6-8 hours of ischemia. After 24 hours, the muscle shows
only slight histologic changes, despite the fact that it is dead and will undergo
necrosis later. Muscle damage is related to the duration of ischemia. Nerve dam-
age is related to the compartment pressure. At first there is loss of conduction,
which quickly returns when the pressure is lowered, but prolonged compression
causes nerve degeneration.
Compartment pressures may be measured by several techniques (Fig. 19-9).
The wick or slit catheter is very satisfactory; however, special catheters are not
always available. A very suitable replacement is an epidural catheter (from the
anesthesia department), which has holes in the sidewall at the tip. Special
patented bedside units have been developed but are expensive and fragile. We
no longer use them. With a suspected compartment syndrome, we prefer to
have the help of the anesthesia department who routinely monitors arterial and
venous pressures. They have the equipment. We do this in the ER, OR, or ICU
with a large bone needle inserted into the compartment and an epidural
catheter then inserted within the needle. Anesthesia then hands you the fluid-
filled line, which is attached to their pressure monitors. You can manually com-
 Measuring Compartment Pressures 279
Compartment Syndromes

ized

Figure 19-9. Mubarak’s method of measuring intracompartmental pressure.The

“wick” or “slit” end may not be available.The anesthesia department can provide
an epidural catheter, which has many small holes in the side wall of the distal tip of
the catheter.

press the compartment, with the catheter in place, to show a fluid wave on the
monitoring screen, to assume that you are in the compartment and that the
equipment is functioning
However, whichever you choose, you should become familiar with one tech-
nique before you are confronted by a problem case. We usually measure pres-
sure in children under general anesthesia, but it can be done using local anes-
thesia. Do not inject a local anesthetic into the muscle.
Why measure the pressure? If you rely on clinical signs alone, you will do fas-
ciotomies too late and too infrequently. Numbers galvanize you into action and
will carry weight in your struggle to get into the operating room quickly.
What should you do if you believe that a child has a compartment syn-
drome, but the pressure in both deep and superficial compartments are normal?
Check the equipment. Repeat the test in an hour or two. If technology contin-
ues to contradict common sense, do a fasciotomy despite the pressure numbers.

Differential Diagnosis of a Compartment

Syndrome
Fracture pain, a lonely child, an arterial injury, and a nerve palsy may each re-
semble a compartment syndrome. A Doppler pulse measurement and a pressure
measurement will distinguish these.

Care of Compartment Syndrome

On suspicion of a compartment syndrome, the cast and padding should be split
to the skin and spread apart widely (bivalved). There is a lot to be said for tak-
ing the front of the cast off to be 100% certain that there are no edges digging
in. An acutely flexed elbow should be straightened. This is a time to forget the
reduction. Contact the parents so that that you do not have to hang around
waiting for a consent for the next stage. Elevate the part to the level of the heart
280 but not above. Does the compartment feel hard? If after 30 minutes decreased
Fractures in Special Circumstances sensation or pain on stretching muscles remains, plan to measure the pressure
preferably under general anesthesia.
Carry out a fasciotomy if the pressure measured by wick catheter extends 30
torr.
Incisions for Fasciotomies
Forearm Upper Limb
The deep flexor compartment is usually affected. The extensor compartment is
affected in 20% of cases. Measure the pressure in the extensor as well as the
deep flexor compartment. The fasciotomy should extend above the elbow into
Volar
the palm; always open the carpal tunnel. Expose the median nerve and the ra-
dial artery. Open the fascia over profundus and flexor pollicis longus.
Do not try to close the wound—little stitches just cut in. The edges can be
drawn together with Steri-strips or a skin staple—rubber band weave method.
With Steri-strips, the edges can be pulled further together at 1, 2, and 3 weeks,
Dorsal by which time closure succeeds. Stitches cut out or leave railway-track scars; the
strips are much better. In some cases, the patient can be taken to the OR for de-
Calf
layed primary closure. Skin grafts are sometimes needed.

Lower Limb
Use the catheter to decide which compartments need opening—peroneal, ante-
rior, superficial posterior, or deep posterior. There are several techniques available.
We prefer a medial and lateral incision; the medial incision opens the posterior
compartments between the tibia and the gastrocsoleus; the lateral incision opens
the anterior tibial and peroneal compartments. They should be opened widely.

NON-ACCIDENTAL TRAUMA
Medial Incision
Although assault has been a criminal offense for centuries when directed toward
adults, it has only in the last hundred years been considered an offense when di-
rected against children. The first action brought on behalf of a battered child
took place in New York City in 1870. Mary Ellen was being beaten daily by her
parents. Attempts to correct this situation by appeals to the police and to the
District Attorney’s office were unsuccessful. Eventually, an action was brought
Lateral Incision by the American Society for Prevention of Cruelty to Animals, which succeeded
because Mary Ellen was certainly a member of the animal kingdom and was
being cruelly abused.
Today, child abuse is a major pediatric problem. Physical abuse affects about
225 children per million of population. Two percent to 3% of abused children
die; the mortality rate of battering is equal to or greater than that of leukemia.
Why a parent should want to injure or kill their own offspring remains a deep
philosophical question. Much thinking has been devoted to the topic. Interest-
ingly, animals (dogs, lions, domestic cats) sometimes willfully abandon or kill
their offspring. Thus parental, imposed injury may represent a poorly under-
stood innate biological element. In most cases, simple explanations can be
found (high family stress, poverty, poor family support, separation of parents,
psychological or psychiatric disorders).
The gradual recognition that the cause of unexplained multiple fractures in
children was the result of abuse was slow to penetrate the medical conscience.
Prior to 1950, children with multiple fractures and a subdural hematoma were
thought to perhaps have a metabolic bone disorder (Caffey). Reading these
early descriptions, in the light of modern understanding, is frightening. In
Figure 19-10. This infant presented with a history that she slipped off a bathroom counter while having a bath. She had a humeral fracture,
a tibial fracture (in a later stage of healing), and multiple rib fractures.This is diagnostic of nonaccidental trauma.

1954, Kempe coined the term “the battered child syndrome,” and received wide
medical and lay press exposure, leading to our understanding of the disorder.
Each year, each of our institutions (The Hospital for Sick Children, Toronto,
Children’s Hospital—San Diego) treats several hundred abused children. The
incidence of child battering is three times as great as that of congenital disloca-
tion of the hip or of clubfoot. Failure to recognize that a fracture in a young
child is due to abuse can be fatal. If the child is treated as a straightforward frac-
ture and sent home, he/she may be killed (by the abuser). Each of our orthope-
dic departments has suffered through this tragic sequence in our early years.

Recognition of Abuse
Battered children may come to the hospital with head injuries; with visceral in-
juries, fractures, or bruises; or with all of these (Fig. 19-10). Twenty-five percent
to 50% of abused children have fractures. The humerus, femur, and tibia are
the most commonly fractured long bones. The corner or bucket-handle type
fracture was thought to be the most common pattern, but recent studies suggest
a transverse fracture as the most common (King et al). In King’s series, spiral
fractures (26%) were much less common than transverse fractures (48%).
In many cases, a “normal fracture” plus a suspicious social history is all that
you have as a lead. If you do not inquire, for instance, the nature of the injury
etc., you may miss the pattern. The typical patterns of child abuse include:
Multiple Injuries Over a Period of Time. Some fractures are new and some are
old. Infants commonly sustain Type I epiphyseal separations. If these are ma-
nipulated every day, a characteristic appearance is produced. A skeletal survey is
mandatory; it may show healed rib fractures with more recent limb injuries.
“Corner” fractures (Fig. 19-11) or “bucket-handle” fractures (Fig. 19-12) are
commonly seen. Transphyseal distal humerus fractures are a “classic” child
abuse injury (Fig. 19-13).
Although these radiographic appearances are diagnostic and much used as illus-
trations, it should be realized that they are unusual. Most battered children have
fractures indistinguishable from those produced in everyday life (Fig. 19-14).
Evasive Explanations. “He must have fallen out of his crib.” “He fell down
Figure 19-11. Typical “corner fracture”
three days ago.” Considerate parents bring their children right away when they of the distal femur.This is due to repetitive
are hurt, and they are sure of the cause of injury. In fact, few children who fall stress and is almost always diagnostic of
do themselves any harm. Levin studied 100 infants who fell (and these were child abuse.
only the falls that alarmed mother) and not one gave cause for concern. 281
282
Fractures in Special Circumstances

At Injury

After Treatment

Figure 19-12. Classic “bucket handle” fracture of the distal tibia in a very young child. This
fracture is common in child abuse.

Figure 19-13. Transphyseal fracture of

distal humerus in a very young child. One
must think of child abuse in such a case. A)
At injury. B) After reduction plus K-wire
fixation.

Figure 19-14. The most common frac-

tures due to child abuse are also the com-
mon fractures that occur in nonabuse
childhood.A) Typical femur fracture—most
common children’s fractures are of a spiral
type. Abuse can be determined only by the
history. B) Typical humerus fracture in in-
A B
fancy—does this mean abuse?

On the other hand, recent experience with large immigrant families in

crowded housing contradicts Levin’s study. Having five siblings in one family,
all younger than age 6 years, jumping on a bed or sofa in a tiny apartment com-
monly produces a limb fracture in the youngest one. Your detective work be-
comes more complex. Hennrikus and Shaw, in Fresno, have directly refuted
Levin’s study.
Lack of Tenderness. Parents are gentle as they handle an injured child. “Batter-
ing” parents sometimes handle the child like a sack of potatoes and are oblivi-
ous of his cries. Once in an interview, I (M.R.) asked the parents, “Is he a good
boy?” The father replied, “No, he is very bad.” I then inquired, “What do you
do when he is bad?” Father then grabbed the boy’s arm—his thumb fitting ex-
actly to a large bruise on the boy’s arm—and shook his fist at him.
History of Previous Obvious Injuries. Some children are already known to the
social service because of family problems. Others have been seen in emergency
departments before. This information is difficult to obtain but sometimes 283
emerges later. Non-Accidental Trauma

Management
A high index of suspicion is warranted. Statistics suggests up to 10% of all in-
juries in children younger than the age of 2 years are due to inflicted injury. The
doctor should approach all fractures in this age group as potential examples of
abuse until he has been convinced otherwise. In much of the western world,
doctors are required by law to inform the social services whenever there is a sus-
picion of child abuse. This law protects not only the child (and siblings) from
further injury but the doctor from legal proceedings.
Whether or not the injury itself demands admission, the child should be ad-
mitted for protection and to provide time for investigation. The family can be
advised that the child must be examined and tested to determine the cause of
the fracture. Often, formal casting can be delayed (use traction or a splint)
while awaiting full social services evaluation.
The doctor may find himself or herself in a strange position that of acquiring
evidence against the parents as well as trying to provide them with counsel. The
social science worker has much to offer in these circumstances but needs sup-
port from you. They will be able to alleviate the strains in the family by using
community resources, educating the family in child rearing, and perhaps put-
ting them in contact with Parents Anonymous, an organization of reformed
child abusers. In the future parenting courses in schools may help to prevent
child abuse in future generations.
If a child has been seriously injured, the parents may be charged with child
abuse and the child temporarily placed in a foster home. In the end, a common
judicial view is often taken that the child is better off with his or her own par-
ents, even in an indifferent home, than in long-term foster care. Different states
(United States) have differing philosophies in interpreting the rights of the bio-
logical parents to raise their child versus the states right to be sure that children
are raised humanely. The size of the adult prison population in North America
suggests that no state has a “clearly just right” philosophy on the matter.

The Battering Child

A 6-week-old child was brought to the emergency department with symmetrical
spiral fractures of the humerus (Fig. 19-15). The parents thought the arms had
been caught in the sides of the crib—an immediately suspicious explanation. In-
stead, the babysitter’s children were the culprits—whether in play or in malice
was never determined. Adelson has recently described cases where infants were
killed by other children. Some of these killings were due to sibling rivalry.

Munchausen by Proxy Syndrome

Munchausen syndrome is named after Baron von Munchausen, a repeated teller
of exaggerated tales. In the adult medical world, such patients are characterized
by habitual presentation for hospital treatment of an apparent acute illness, the
patient giving a dramatic and usually medically “correct” history, all of which in Figure 19-15. The babysitter’s children,
the end is untrue. age 7, 5, and 2 years, had produced these
symmetrical fractures.
In the Munchausen by proxy syndrome, a parent creates such a disease in the
child, mandating unneeded admissions, extensive workups, and unneeded op-
erations. Orthopedics must be careful of this syndrome. The line between an
overly demanding (but normal) parent and a Munchausen by proxy parent is
sometimes narrow. A 2004 New Yorker magazine article brilliantly elucidates
this puzzling condition.
284
Fractures in Special Circumstances The Skeletal Survey—When Is It Overdone?

This child had a simple ankle fracture but

the inexperienced ER doctor wasn’t clear
on the history and called the social service
team. A total of 18 films were taken with lit-
tle else learned. Although generally indi-
cated, the skeletal survey produces a great
deal of irradiation. Some wonder if there is
still a role for a “babygram” in the low index
of suspicion case.

284
Overdiagnosis and Family Stress 285
Pathologic Fractures
As the child abuse syndrome has become better recognized, some families end
up being falsely accused. For example, if an infant has one fracture (say
humerus or femur) and the finding of “periostitis of the newborn” (a known
phenomenon), the investigative team can be misled. Also, subtle forms of osteo-
genesis imperfecta may cloud the issue.
Sometimes the orthopedist needs to help educate the social worker regarding
the potential for fracture associated with rough play. Hennrikus and Shaw have
nicely illustrated this in their important 2003 publication. A team approach is
required to best serve the family.

PATHOLOGIC FRACTURES
By definition, a pathologic fracture is one through weak bone of abnormal
composition. There are multiple causes as noted.

Local Bone Lesions

Simple Bone Cyst. Most pathologic fractures in the upper humerus are caused by
bone cysts. (Unicameral bone cyst (UBC)—simple bone cyst—the terms are used
interchangeably.) Minimal displacement is the rule. Diagnosis can be confidently
made on the radiologic appearance alone (Fig. 19-16). Although the term simple
bone cyst is commonly used, it may lead you and the parents to underestimate the Figure 19-16. Midshaft unicameral bone
chemistry of the lesion. As one wit once said, “Don’t call it a simple bone cyst cyst in a child. He had recurrent fractures
until you have treated ten cases. They are very often not simple (to manage).” despite steroid injection treatment. The
The presence of the cyst does not interfere with healing, and the fracture is CT scan shows the cortical break after his
treated as if the cyst is not present. However, if nothing is done, refracture is most recent fracture.
likely.
Neer found that 80% of children had one to three refractures after the initial
injury and that 10% had some deformity as a result. For this reason, he advo-
cated treating all cysts.
Bone cysts occasionally produce fractures in weight-bearing bones such as
the neck of the femur. Deformity is likely. Bone cysts may breach the growth
plate. Growth disturbance and even collapse of the femoral head may follow.
The same (growth arrest) can occur in the proximal humerus.
Treatment—Steroid Injection. The treatment of cysts has been transformed by
the discovery that injection with methylprednisolone will produce healing (Fig.
19-17). Scaglietti, Marchetti, and Bartolozzi consider it important to use two

UBC—Early (9-year-old) Steroid Injection Bone Bridge to Epiphysis

Figure 19-17. Nine-year-old boy with a simple bone cyst (UBC). He has been treated with steroid injection three times. He has developed
a physeal bridge and his humerus is now 2 cm short.
286
Fractures in Special Circumstances
At Injury
CT Scan
Figure 19-18. Ten-year-old male with a
pathologic fracture of the tibia. The frac-
ture line spirals from the distal nonossify-
ing fibroma up to the main fracture. It is
sometimes difficult to determine what size
of cyst will weaken the bone enough to
produce a fracture.
cannulated needles to enter the cyst under radiographic control in order to
avoid hemorrhage. The exit of clear, yellow fluid confirms the diagnosis, so that
biopsy is usually unnecessary.
Forty to 200 mg of methylprednisolone acetate (Depo-Medrol) is intro-
duced, depending on the size of the cyst. We usually do this under anesthesia. If
the cyst is showing no signs of healing at 3 months, the injection is repeated
and may be repeated again. In 72 cases Scaglietti followed for more than 18
months, the results ranged from complete healing in 36% to a clearly positive
result in 96%. Surgery for bone cysts is now much less common but is occa-
sionally required.
Current methods to replace steroid injection with bone marrow injection
and vigorous methods of breaking down the wall of the lesion with strong,
curved needles (Weintraub) appear to be successful but are more complicated to
perform than steroid injection. We have tried the new methods and found them
unnecessarily complicated. We have reverted to steroid injection, which is very
effective, providing you are very persistent (a somewhat un-American trait—at
least for surgeons serving in an “injection only” role).
Curettement plus bone grafting may be required in the few cysts, which are
large and recalcitrant. This is most commonly considered in large proximal
femoral cysts, which risk intertrochanteric fracture (although even these lesions
can heal with persistent steroid injections). Any curettement must be delayed
until the cyst has grown away from the physis (otherwise physeal closure, which
sometimes occurs even without curettement, will be attributed to your industri-
ous scraping).
Nonossifying Fibroma. The distal tibia, followed by the distal femur, are the
most common sites of the fracture through cortical nonossifying fibromas. Cen-
trally placed lesions do not weaken bone. The risk for fracture is greater then one
might think, especially in the distal femur and distal tibia (Fig. 19-18).
Most of these fractures are spiral and little displaced. Healing is accompanied
by partial obliteration of the fibroma. Because the diagnosis is obvious, biopsy
is not required. Refracture is unusual. A small series of large fibromas has been
reported. Some of these were grafted initially because of their size and risk for
fracture or because of the doubts about the diagnosis. CT scans are often per-
formed in large lesions to clarify size and risk for fracture (cortical break, corti-
cal thinning).
Miscellaneous. Almost every type of bone lesion has been associated with a
pathologic fracture (Fig. 19-19). Fibrous dysplasia of the proximal femur is a
typical example. Also, congenital pseudarthrosis of the tibia (often in a patient
with neurofibromatosis) may present with pain and a pathologic fracture.
General Bone Weakness
Neuromuscular Disorders. In children, a major cause of pathologic fractures is
osteoporosis resulting from neuromuscular disorders. Fractures are especially
common in these patients after operation and cast immobilization (because of
joint stiffness and disuse atrophy).
Cerebral Palsy. Fractures in children with cerebral palsy (CP) are uncommon,
unless they are on anti-seizure medicines, which affect vitamin D metabolism.
Children with CP who have had reconstructive surgery, and then are immobi-
lized in a cast commonly develop fractures. Routine care is generally effective.
However, in bed-fast patients, particularly those with contractures and convul-
sions, fracture is common. Very simple methods of treatment are needed for
Figure 19-19. This eight-year-old boy presented with right hip pain and was found to have a subtle fracture line in a large bone lesion in
the intertrochanteric area. Diagnosis was polyostotic fibrous dysplasia.The femur lesion was excised and bone grafted and fixed with flexible
nails.The left foot was treated due to a recurrent fracture. His other lesions are being monitored.

these patients, because pressure sores are difficult to avoid. Referral to the meta-
bolic bone disease unit may help in patients who get into a vicious fracture cycle
(cast off-refracture-cast off-refracture).
Muscular Dystrophy. The policy of keeping children with Duchenne dystro-
phy on their feet as long as possible, by means of surgical releases and bracing,
led to more lower limb fractures in this group. Fractures occur at all sites and re-
quire typical cast immobilization. The aggressive approach to encourage walk-
ing as long as possible has been tuned down in some centers (Children’s Hospi-
tal—San Diego), resulting in fewer fractures.
Spina Bifida and Paraplegia. Diagnosis is often delayed when a fracture occurs
in an anesthetic part of the lower limb. The surgeon is confronted with a
swollen, hot, red limb in a child with a slight fever—symptoms that simulate

287

Figure 19-20. Fracture in osteopetrosis
in a girl of 8 years. This family of affected
children sustains frequent fractures.
Figure 19-21. An extreme example of
hyperplastic callus in osteogenesis imper-
fecta. This phenomenon has only been
noted in association with dislocation of the
radial head.
288
acute osteomyelitis especially in physeal fractures that present exactly as an in-
fection. We have coined the term Charcot physis to describe the sequence of
progressive pain—free physeal injury—partial healing—further damage that
can close the physis.
Fracture is very common after orthopedic operations and cast immobiliza-
tion; supracondylar and trochanteric fractures of the femur are so common after
hip surgery that I warn the parents to expect them. The incidence is reduced by
insisting that the child stand for a few hours every day while in the postopera-
tive cast.
Rapid healing is the rule for fractures in neuromuscular conditions. Com-
monly, hyperplastic callus is seen. There is no single explanation for the massive
volume of callus; repeated movement, unspecified neural influence on bone for-
mation, and hyperphosphatemia are possible reasons.
Treatment should be simple and carefully supervised. An early return to
brace-wearing for the tibia, or a well-padded weight-bearing cast, is advised in
order to prevent further disuse osteoporosis and a succession of fractures.
Growth plate injuries may present a diagnostic challenge. We noted premature
growth arrest occurred in five of the nine patients with neurogenic physeal frac-
ture (Charcot physis) and advised immobilization and non-weight-bearing
until full healing has occurred.
General Bone Disease. Fractures in osteopetrosis and osteogenesis imperfecta
are common. Displacement is usually slight, and there is much to be said for
simple splinting. Air splints have also been tried for osteogenesis imperfecta
(Fig. 19-20, 19-21).
FRACTURES IN SPECIAL
GROUPS OF PATIENTS
Head Injuries with Long Bone Fractures
When a child is hit by a car, Waddell’s triad of injuries is commonly produced. A
child’s femur is at the level of the bumper; the trunk is at the level of the hood;
the child may receive a blow to the head on landing on the road (Fig. 19-22).
Fractures of the femur and the shaft of the humerus can be difficult to man-
age in restless, recumbent children. If the head injury is minor and expected to
clear in a day or two, the fracture should be immobilized by simple splinting
until routine methods may be employed. Fat embolism may be blamed for pro-
longed unconsciousness if this is not done.
When decerebration is likely to be prolonged beyond a few days, internal
traction is advised (Fig. 19-23).
Figure 19-22. Waddell’s Triad of injuries in children.
 289
Fractures in Special Groups of Patients

Figure 19-23. This fracture was uncontrollable owing to a severe head injury. Plating avoids
the risk of producing avascular necrosis of the femoral head from damage of the epiphyseal
arteries. Antibiotic cover is wise because poor nutrition and multiple tubes increase the risk
of infection.

Fractures in the Newborn

The literature is full of birth injuries of every type. We still see a fair number (clav-
icle, humerus) in especially large babies (Fig. 19-24). Long bone fractures are easily
recognized, but separations of unossified epiphysis present a challenge to diagnosis.
There may be difficulty distinguishing between a birth fracture and child abuse.
Callus appears within 7 to 10 days around a birth fracture. Truesdall, in 1917, ana-
lyzed 33,000 deliveries for skeletal injury and found 85 injured children. There
were no greenstick fractures, and only 10% were epiphyseal separations. The
humerus and clavicle were most commonly fractured, and a Velpeau bandage con-
trolled these well. Fractures of the midshaft of the femur accounted for 12%, and
traction was required to prevent gross overriding and anterior angulation.

Hemophilia
A well-controlled hemophiliac today is free of crippling deformities and can
lead quite an adventurous life. Fractures present no special problem if cryopre-
cipitate is administered. Fractures heal at the normal rate.
The child should be either admitted or monitored by a well-run hematology
service, which can monitor the factor levels, and carefully watched for a few days. Figure 19-24. This type of humeral frac-
A greater risk than fractures, which provoke immediate attention, is a slow ture is common in the newborn. Large ba-
bies seem to be at greater risk.
bleed into a closed compartment, which results in Volkmann’s contracture. This
obviously demands urgent decompression.

Renal Dystrophy and Rickets

Children waiting for a kidney transplant may develop profound osteodystro-
phy. A slow slip of the upper femoral epiphysis should be pinned as soon as it is
noted. Dialysis is no bar to anesthesia (Fig. 19-25).
290
Fractures in Special Circumstances

Figure 19-25. (1) Vitamin D-resistant rickets.This child was receiving insufficient vitamin D.
(2) A slight fall produced a pathologic epiphyseal separation.The dosage of vitamin D was in-
creased. (3) At 2 months, the separation has healed.

STRESS FRACTURES
The most common sites of stress fracture in children are the upper third of the
tibia, the lower half of the fibula, followed by metatarsal, rib, pelvis, femur and
humerus. They are particularly common in the spring, when children become
active after a winter of inactivity. The radiographic appearance may be confused
with a neoplasm or an infection, but the distinction is usually clear. If the diag-
nosis is in doubt, serial radiographs should be obtained over a short period of
time (Fig. 19-26). A bone scan will demonstrate a stress fracture earlier than a
radiograph and occasionally a CT scan or MRI is needed to differentiate a sub-
tle, healing stress fracture from a Ewing’s sarcoma.
Stress fractures through the distal femoral growth plate have been described
in athletes. Abstinence from a sport may be sufficient treatment, but a cast is
helpful if a child is overly active, if pain is marked, or if the fracture looks as if it
may become complete. All stress fractures of the femoral neck should be immo-
bilized in a spica or fixed with threaded pins.

A B C

Figure 19-26. This runner had recently increased his mileage to 30 miles per week. One
day, the right upper tibia became tender and the patient began to limp. A) The x-ray film at
this time was normal. B) Bone scan showed a hot transverse bar—the typical first sign of a
stress fracture. Later, periosteal new bone forms and the hot area becomes more diffuse and
less characteristic. C) After 3 weeks, the diagnosis can be made radiographically. Two years
later, the patient developed the same symptoms in the other leg.The radiograph was normal
at Elsewhere General Hospital and the patient was told there was nothing the matter. When
his request for a scan was turned down he went elsewhere. (Courtesy of David Gilday, MD.)

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Clin 1998 Aug:14(3):371–83
Holden CEA. The pathology and prevention
of Volkmann’s ischemic contracture. J
Bone Joint Surg 61B:296,1979
Isaacson J, Louis DS, Costenbader JM: Arte-
rial injury associated with closed femoral-
shaft fracture. Report of 5 cases. J Bone
Joint Surg 57A:1147, 1975
Karlstrom G, Lonnerholm T, Olerud S:
Cavus deformity of the foot after fracture
of the tibial shaft. J Bone Joint Surg
57A:893, 1975
Matsen FA, Mayo KA, Krugmire RB et al: A
model compartmental syndrome in man
with particular reference to the quantifi-
cation of nerve function. J Bone Joint
Surg 59A:684, 1977
Mubarak SJ, Carroll NC: Volkmann’s con-
tracture in children: Aetiology and pre-
vention. J Bone Joint Surg 61B:285,
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Mubarak SJ, Owen CA, Hargens AR et al:
Acute compartment syndromes. Diagno-
sis and treatment with the aid of the wick
catheter. J Bone Joint Surg 60A:1091,
1978
Nonaccidental Trauma
Adelson L: The battering child. JAMA 222:
159, 1972
Caffey J. Multiple fractures in long bones of
infants suffering from chronic subdural
hematoma. Am J. Roentgonol. 56:163–173,
1946
Hennrikus WL, Shaw BA. Injuries where
children repeatedly fall from a bed or
couch. Clin Orthop 407:148–151, 2003
Kempe CH, Silverman FN, Steele BF,
Droegemueller W, Silver HK. The bat-
tered-child syndrome. JAMA 1962 Jul
7;181:17–24.
King J, Dietendorf D, Apthorp J et. al. Analy-
sis of 429 fractures in 189 battered chil-
dren. J Pediatr Orthop. 8:585–589, 1988.
Levin S: Infant fall-out. South African Med J
46:586, 1972
Loder R, Bookout C. Fracture patterns in
battered children. J Pediatr Orthop.
5:428–433, 1991.
Van Stolk M: The Battered Child in Canada.
Toronto, McClelland & Stewart, 1972
Pathologic Fractures
Devas MB: Stress fractures in children. J
Bone Joint Surg 45B:528, 1963
Drennan DB, Fahey JS, Maylahn DJ: Frac-
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Fry K, Hoffer MM, Brink J: Femoral shaft
fractures in brain-injured children. J
Trauma 16:317, 1976
Godshall RW, Hansen CA, Rising DC:
Stress fractures through the distal femoral
epiphysis in athletes. Am J Sports Med
9:114, 1981
Neer CS, Francis KC, Marcove RC et al:
Treatment of unicameral bone cyst. J
Bone Joint Surg 48A:731, 1966
Petersen EA, Haase J: Unstable fractures in
children with acute, severe brain injury.
Acta Orthop Scand 45:321, 1974
Scaglietti O, Marchetti PG, Bartolozzi P:
The effects of methylprednisolone acetate
in the treatment of bone cysts. J Bone
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Sillence DO. Osteogenesis imperfecta; an ex-
panding panorama of variance. Clin Or-
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 Accident Prevention,
20
Risk, and the Evolving
Epidemiology of Fractures
Dennis Wenger

• Accident Prevention 293

• Accident or Cultural Consequence? 294
• Cultural Patterns and Fracture Risk 299
• Analysis of Pediatric Orthopedic
Musculoskeletal Injuries 300
• Mandated Sport for Every Child—Risks
and Benefits 301
• Childhood Obesity and Fracture Risk 302

“The great end of

ACCIDENT PREVENTION
In the last edition of this text, considerable attention was given to accident pre-
life is not knowledge
vention strategies. Mercer Rang became a leader in promoting the concept of but action”
safer playgrounds, better sports equipment, and auto safety issues (both for pas-
sengers and pedestrians). —THOMAS HENRY
Tremendous progress has been made. Automobiles are much safer (better
design [structural “cage”], airbags [front, side], better brakes [ABS] and better HUXLEY
seat belts—plus laws that mandate their use). The routine (and usually legally
293
294
Accident Prevention, Risk and the
Evolving Epidemiology of Fractures
Figure 20-1. Helmet wear is fortunately
becoming the standard for many sports.
Efforts to prevent head injury have been a
huge success. (Photo courtesy of R. Knud-
son.)
Figure 20-2. Children love the thrill of
riding motorized vehicles. (Photo courtesy
of R. Knudson.)
Figure 20-3. Skateboarding is a spectacu-
lar American-born sport that not only im-
proves one’s sense of balance but also in-
creases the chance of fracture. (Photo
courtesy of T. Hooker.)
mandated) requirement for helmet use in bicycling and other sports (Fig. 20-1)
has been of immense value in reducing head injuries. In many neighborhoods,
the playgrounds are safer, due to better design and soft surfaces (replacing com-
pacted dirt).
Furthermore, in developed countries, the establishment of effective trauma
systems including, in many cases, pediatric trauma centers has helped reduce
the morbidity and mortality associated with severe musculoskeletal injury. Also,
the rapid growth of pediatric orthopedics as a subspecialty of orthopedic sur-
gery has been of great value in reducing fracture morbidity because of research
produced by the major pediatric orthopedic centers that have an interest in
trauma. The concentration of experience in treating severe fractures has greatly
improved the quality of fracture care in North America. The methods learned
by fellows who have trained in these centers are now available to injured chil-
dren, not only in large but also in medium-sized cities.
Despite this great progress, not all the news is good regarding risks to chil-
dren and the incidence of fractures.
ACCIDENT OR CULTURAL
CONSEQUENCE?
The term accident is defined in the Oxford American Dictionary as follows:
1. An unexpected or undesirable event, especially one causing injury or damage
2. Chance, fortune (we met by accident)
We continue to marvel at how our culture uses the term in reference to chil-
dren's fractures (Fig. 20-2). Parents will bring in a 6-year-old boy who was driv-
ing his own mini-racing motorcycle in the desert with a large number of family
members. The child has multiple fractures (one open) with the parents dis-
traught over the “accident.” In many cases, the term “accident” has become a
euphemism for failure to act in a responsible manner. When small children and
powerful machines are involved, this failure borders on neglect.
Vitale and colleagues at Columbia suggest that the incidence of fractures is
increasing in our culture (rather than decreasing) due to cultural patterns that
will be discussed later in this chapter (Galano et al.—see Suggested Readings).
As sports become safer (helmets, pads, etc.), children (and adults) are more
likely to perform with greater speed or at greater risk to achieve the same satis-
faction (Fig. 20-3). The concept of “risk homeostasis” will be discussed later.
Brent and Weitzman, in the Journal of Pediatrics (2004), recently presented a
comprehensive analysis of the environmental risks of childhood in North
America. They noted that accidents are the leading cause of death in children
younger than age 15 years and that many are preventable with safety education.
Leaders in pediatric orthopedics have made a concerted effort to work on devel-
oping methods that might prevent fracture. Yet the incidence of fractures ap-
pears to be increasing rather than decreasing in our culture.
Brent and Weitzman group environmental risks to children with the major
ones as noted below. Many of these subgroups can lead to musculoskeletal injury.
! Trauma from falls
! Vehicular accidents
! Burns
! Choking, strangulation
! Drowning
! Bicycling
! Pedestrian injuries
! Guns
! Sports injuries 295
! Power tools/farm tools Accident or Cultural Consequence?
! Obesity
! Alcohol, smoking, drug use
In this chapter, we will focus on the categories with risk for musculoskeletal “In California, a parent who
injury in children; that is falls, vehicular accidents, sports injuries, and power
tools. A growing, but less easily categorized group, not clearly demarcated in the fails to properly restrain a
review by Brent and Weitzman, includes wheeled vehicles that are not formally child is fined $350 (per
vehicular (skateboards, rollerblades, “wheelie” shoes, etc.) that can be used in child)”
very dynamic (even aggressive) ways. Also, the use of gasoline-powered mini-
bikes and scooters by even the very young is in a “growth pattern.”

Falls
Infants can suffer head injuries when falling down stairs, off of beds, or against
sharp, pointed furniture. Toddlers and children aged 5 to 19 years often fall
from windows, stairs, trees, garage roofs, and ladders. Trampoline injuries pro-
duce many fractures (as well as head and neck injuries). More than 60,000 chil-
dren had emergency room visits for trampoline injuries in 2002. When multi-
ple children jump at once, injury is more likely and younger children are at
greater risk for fracture.
Histories for falls can be so odd as to confound those trying to separate ordi-
nary trauma from nonaccidental trauma. A parent of one of our patients said
that she dropped her child (wet from a bath) into a toilet with a resulting limb
fracture. She proved to be a sound, loving mother and her rapid retrieval skills
kept the child off the drowning list!

Vehicular Accidents
Passenger injuries are extremely common in children younger than age 10; these
children should never ride in the front seat of a car. Education and regulations re-
garding properly installed car and booster seats have improved this circumstance.

Safety—Children in Cars
Motor vehicle crashes are a leading cause of
injuries and death for children.
When used correctly, child safety seats can
reduce fatal injuries in cars by 71% for infants
and 54% for children from age 1-4.
More than 95% of child safety seats are NOT
used correctly.
IT IS THE LAW that children must ride in a safety seat or booster, prop-
erly used, until they are at least 6 YEARS OR WEIGH AT LEAST 60
POUNDS.

Courtesy of Trauma Department—

Children’s Hospital—San Diego,
reproduced with permission.
296
Accident Prevention, Risk and the
Evolving Epidemiology of Fractures
Figure 20-4. Younger and younger chil-
dren are participating in motorized vehicle
activities. (Photo courtesy of S. Nelson.)
Figure 20-5. The razor scooter has
proven to be a great source of new frac-
tures. The nature of the fall provides a
“Smith pattern” injury of the distal radius.
The tiny wheels, and large sidewalk cracks
are not a good mix. (See Kiely et al.—Sug-
gested Readings.)
Safety Seat Guide
Children must ride in a rear-facing (facing toward the
back of the car) safety seat until they are at least
1 year AND weigh 20 pounds.
Kids over 1 year and between 20-40 pounds may
be in forward-facing safety seats.
Young children between 40
and 60-80 pounds (usually 4 to
8 years old) MUST ride in a
booster.
Children who are over 4 feet 8 inches AND at least
80 pounds can fit correctly in lap/shoulder belts.
Courtesy of Trauma Department—Children’s Hospital—
San Diego, reproduced with permission.
New government-mandated latch systems, which allow a nationally standardized
method for attaching child seats to the automobile frame, will make auto travel
safer. Legislation-mandated child car seat use also helps. In California, a parent
who fails to properly restrain a child is fined $350 (per child).
Also, children younger than age 10 are at great risk for death from pedestrian
accidents including being run over by the family car in their own driveway (lack
of vision from the height of the new, taller SUVs have added to the problem).
For teenagers, impulsive behavior, speeding, and inattentive driving as well as
drunken driving make auto accidents a leading cause of death in this age group.
The Europeans may have a better pattern (drink early and with family, drive
late—age 18 years).
We see many young patients whose parents have aspirations for their chil-
dren to become professionals in motorcycle racing and/or daredevil motorcycle
jumping activities. If you are good enough you can “get a sponsor” (equipment,
etc.) at a very young age (Fig. 20-4).
Sports Injuries, Bicycling
Children riding a bicycle, tricycle, scooter, or skateboard or using a razor
scooter (Fig. 20-5) should use a well-fitted helmet to reduce the risk for head
injury. Bicycling is a risk for children and ideally would be restricted to daylight
use, in safe areas, with helmet use. Children who play football, baseball, soccer,
hockey, and lacrosse are advised to always wear proper protective equipment
and be properly supervised.
Such reports and recommendations represent the ideal and are a bit like rec-
ommending a balanced diet for all children. In reality, most children who skate-
board, ride bicycles, or play sports do them in an unsupervised manner and do
not wear equipment either because they are not properly educated or in many
cases, because they cannot afford the equipment. It would appear that fracture
risk is reasonable controlled in organized sports for children but is increasing in
the uncontrolled environment of the “street wheel scene.”
Playgrounds and Sport
Recently, there has been a substantial focus in the first world on the risks that
poorly designed playgrounds provide to children, thus increasing their risk for
 297
Facts About Bike Safety Accident or Cultural Consequence?

Head injury is the leading cause of death in

bicycle crashes.
Using a helmet can lower death rate by 75%.
Only about 15% to 20% of children wear helmets.

Courtesy of Trauma Department—Children’s Hospital—San Diego, reproduced with permission.

fracture (Fig. 20-6). Poor landing surfaces such as hard-packed dirt or asphalt
can be changed to surfaces such as rubber mats, wood shavings, or soft sand.
Slowly, we are beginning to see playgrounds becoming safer. (Perhaps plaintiff
attorneys can be given a bit of credit—once the issue of poor playground design
and fracture risk became apparent, successful lawsuits against schools and parks
ensued.) Now the playgrounds are safer. Unfortunately, the pendulum has
swung too far and now some organizations are unwilling to provide play-
grounds because of insurance cost (due to legal risk).

Negative Effects of “Very Safe Playgrounds”

A second, and less well-understood consequence of the move toward low-
height, low-risk playgrounds is the denial of athletic freedom and risk that some
believe develop balance and physical dexterity in childhood. The traditional
view of child development included that playgrounds should include adven-
turesome swinging ropes, relatively high slides, and swings with long ropes or
chains and a large arc. Complex climbing devices, such as monkey bars, were Figure 20-6. Playground safety is impor-
common (Fig. 20-7). tant. This boy was enjoying a day at the
park when the weathered plywood at the
The idea behind such equipment included that the activity developed a
top of a slide finally failed. He had fractures
child’s dexterity, physical stamina, and ability to face risk. It was accepted that in three limbs.
an unwary child might be injured but the risk-benefit ratio favored adventurous
design. The Boy Scouts and Outward Bound have this focus for older children.
In summary, modern super safe, “low rise” playground equipment may decrease
the injury rate but at the same time prevent a child from achieving his or her
full physical abilities by limiting play experiences that demand judgments re-
garding distance, height, timing, etc.
In our culture, the need for adventuresome play that involves risk has to a
great degree moved from the playground to other venues such as small-wheeled
scooters, rollerblades, skateboards, racing bicycles, motorized scooters, and
small motorcycles, which have proven to be a prolific new cause for fractures.

Power Tools
Brent and Weitzman noted that nearly 10,000 children, age 15 and younger, Figure 20-7. More complex, high off the
are injured by lawn mowers each year (Fig. 20-8). Young children should not be ground playground equipment helps to de-
nearby when a power mower is used and these experts suggest that children velop balance and judgement (in a Darwin-
ian way). In the modern era, such play-
younger than 12 years should not be allowed to operate a walk-behind mower
grounds are being reigned in because of
and children younger than 14 should not operate a riding mower. Physicians the risk of injury. Lawyers have helped to
with agricultural roots in America, understanding the benefit of responsibility guide this trend. Is it really a good trend for
learned at an early age, might quarrel with this advice. our children?
298
Accident Prevention, Risk and the
Evolving Epidemiology of Fractures
Figure 20-8. Young children should not
use dangerous rotary lawn mowers. The
risk for soft tissue injury and scalping type
fractures is great, especially if the grass is
wet. (Photo courtesy of C. Farnsworth.)
After Healing of
Distal Radius Fracture
Figure 20-9. We now see about 50 recurrent fractures per year. This case is typical with the refracture occuring 6 months after the origi-
nal injury—skateboarding was the cause of both.
Other Risks—Aggressive Sport or
Calcium Deficiency?
A recent study, utilizing the population base of Olmstead County, Minnesota
and surrounding communities, suggested that the incidence of childhood fore-
arm fracture was increasing: 263 per 100,000 population—1969; 372 per
100,000 population—1999 (30 years later).
Although uncertain of the cause, they suggested a changing pattern of physi-
cal activity or decreased bone acquisition due to poor calcium intake or perhaps
both.
They also noted a greater rate of fracture increase in girls (52%) as compared
to boys (32%) with the largest increases in pubertal age children. This female
over male increase led to speculation regarding calcium intake. On the other
hand, another report estimated that in 1971, only 31,000 girls participated in
organized high school sports, whereas 3 million girls participated in 2003. Al-
though increased numbers wouldn’t necessarily increase the risk for forearm
fractures, increased numbers also means that more girls are competing at high
levels (premier leagues), which may increase the speed and ferocity of sport col-
lision. Also, in our experience, girls also love the thrill of the new variety of mo-
torized off-road vehicles.
In our center, we are experiencing an epidemic of repeat fractures in the same
bones (Fig. 20-9). We attribute this to aggressive lifestyle rather than “soft
bones.”
Refracture Reduction of Repeat Fracture
CULTURAL PATTERNS AND 299
FRACTURE RISK Human Need for Risk—War Versus Sport?

Throughout history, children likely suffered injuries while working with their
parents, hunting, and in adventuresome play. With the evolution of advanced
economies, children have had more leisure time allowing play in formal play-
grounds, vigorous sport, as well as exposure to both wheeled and then motor-
ized wheeled vehicles. As already noted, we are now experiencing an increasing
incidence of fractures in children.
Our profession’s reaction to this changing childhood risk has been laudable
with the American Academy of Orthopaedic Surgeons, the American Academy
of Pediatrics, the Pediatric Orthopaedic Society of North America, the Euro-
pean Pediatric Orthopaedic Society, and parallel organizations devoting re-
sources and research toward accident and injury prevention. The goal has been
to decrease the incidence and severity of fractures by methods ranging from
playground design, seat belt use, mandated car seat use, mandated helmet use,
the wearing of proper protective devices for sports, and age and location risks
for all-terrain vehicle (ATV) use.
Unfortunately, the exponential growth of use of automobiles in large cities in
the world have made progress in accident prevention difficult. The number of
vehicles on the streets each day in Cairo, Shanghai, Jakarta, and São Paulo has
skyrocketed over the last 20 years and the design and construction of safe, well-
designed streets and highways has not kept pace. The result is a radical increase
in musculoskeletal injuries, both for drivers and pedestrians. Thus industrializa- Figure 20-10. Children and adolescents
love to sense risk and danger. The growth
tion, the growth of cities, and the use of gasoline-powered vehicles of all types of the “paint ball gun industry” clarifies the
(automobiles to “pocket” scooters) have made life more risky for a child. issue. (Photo courtesy of A. Jacobson.)

HUMAN NEED FOR RISK—WAR

VERSUS SPORT?
Perhaps, an underappreciated reason for an increase in childhood fractures is
the innate pleasure that comes from risk-taking activities (Fig. 20-10). In the
historical era, a large percentage of young males in a culture marched off to war Recommendations by
with often much of the army decimated in a few days (Peloponnesian Wars, the American Academy
American Civil War—Grant's army lost 7,000 men in 20 minutes at Cold Har- of Pediatrics
bor; World War I trench warfare—thousands of men killed within a few days'
No use of ATVs by children or
time).
adolescents younger than 16.
It would appear that the adolescent brain (particularly male) has an innate Use of ATVs should require au-
need to experience risk and that the traditional risks (tribal warfare, hunting tomobile driver’s license and,
wild game with a spear) have been replaced with modern counterparts. The in- preferably, special certification in
creased risk for fractures in male children will be discussed later. ATV use.
No use of ATVs on public
streets or highways.
Risk Homeostasis—Helmets and No passengers on ATVs.
Pads Yet More Fractures No operating of ATVs under
the influence of alcohol.
Advanced cultures have tried to make sports safer with helmet wear for bicy-
No use of ATVs between sun-
cling, well-padded surfaces on ideally designed playgrounds, and strict rules re- down and sunrise.
garding protective gear for organized sport, yet the fracture incidence is increas-
ing. It would appear that risk seekers have found a need for new outlets. Thus Courtesy of Trauma Department—
the rapid growth of “extreme” sports throughout the world, particularly in Children’s Hospital—San Diego,
North America. reproduced with permission.
300
Accident Prevention, Risk and the
Evolving Epidemiology of Fractures
“As helmets, protective
splints, and rules evolve, the
participants simply crank to
a higher level of performance,
speed, and risk”
Figure 20-11. Children of every age
enjoy a variety of sports. The forearm
serves its programmed shock absorbing,
collapse role, much like the hood of a Volvo
in a head-on collision. Better an arm frac-
ture than a skull or neck fracture. This
youthful bull rider suffered bilateral distal
radius fractures with a balanced, symmetric
fall, avoiding more serious injury. (Photo
courtesy of R. Knudson.)
This began with rollerblading, skateboarding, and aggressive bicycle and mo-
torcycle riding. Large numbers of the population enjoy participating in these
sports with a focus on speed and risk. A concept known as the “Extreme
Games” focuses on high-risk sports and is televised internationally each year.
Even the complexity level of gymnastic activities, diving activities, etc., as seen
during the recently televised Olympic games, has escalated to a startling degree.
Each year, we see hundreds of children who have suffered fractures while at-
tempting to mimic the extreme sporting activities that they have seen on televi-
sion. These include skateboarding stunts and motorized vehicle activities. Even
in the well-structured sports (BMX bicycle racing), the development of new
helmets, pads, etc., have been superceded by the demands of the extreme stunts
that the children attempt. Supercross, a popular dirt bike (motorized bike)
competition, is now held in stadiums throughout North America. A profes-
sional circuit has evolved and parents are told that training should start early if
their child is to be competitive—thus the 5-8 year olds that we see (often with
serious fractures) who have been emulating their professional supercross idols.
Risk Homeostasis
This increase in fracture incidence, despite the best intended advice of organiza-
tions regarding safety rules, helmet wear, protective equipment wear, and rules
for organized sports, may represent a variation of what the Dutch (now Cana-
dian) psychologist Gerald Wild has coined “risk homeostasis.” As vehicles are
made safer (air bags, ABS brakes, etc.), drivers drive more rapidly and have
more accidents. A study of taxi drivers, who were rotated between “safety per-
formance vehicles” (air bags, ABS, better suspension) and standard vehicles,
found a higher accident rate in the “safety” vehicles. The drivers simply drove
faster and took more risks!
The same phenomenon is likely in play regarding both official and particu-
larly unofficial childhood “sport” (Fig. 20-11). As helmets, protective splints,
and rules evolve, the participants simply crank to a higher level of performance,
speed, and risk. The helmets remain up to the task, but the limbs serve as
“crumple zones” (to protect the central, vital organs). Thus human reflexes and
protective limb extension (with a fall) serve much like the hood and engine
mounts of a safe Volvo vehicle (front collapses—central “cage” remains intact).
These patterns in no way question the value of protective helmets, protective
splints, and sport rules. Their routine application has greatly improved the in-
jury environment in organized sports. Mandated helmet wear for bicycling chil-
dren, preventing brain injury, is perhaps the most profound example. However,
the limb fracture epidemic continues.
ANALYSIS OF PEDIATRIC ORTHOPEDIC
MUSCULOSKELETAL INJURIES
Vitale and colleagues at Columbia University, through the International Center
for Health Outcomes and Innovation Research, provide additional data on chil-
dren’s musculoskeletal injuries. A recent paper from their center clarifies pedi-
atric trauma as the leading cause of death and disability in children, accounting
for 11 million hospitalizations, 100,000 permanent disabilities, and 15,000
childhood deaths each year in the United States. The direct cost of pediatric
trauma is over $8 billion per year, which is only a fraction of the true total cost
because indirect costs to families and society are impossible to estimate.
They note that the incidence of pediatric trauma in the United States is
among the world’s highest, likely because of the dangers associated with our
 301
Off-Road Vehicle Injuries—Pediatric Trauma Patients Mandated Sport for Every Child—
Risks and Benefits
Average hospital length of stay ! 3.8 days
Hospital length of stay range ! 0–21 days
Average hospital charge for hospitalized ATV trauma patients ! $27,000
Hospital charge range ! $5,500 to $299,289

Courtesy of Trauma Department—Children’s Hospital—San Diego, reproduced with permission.

highly mechanized society as well as the gravity of urban violence. Although the
overall death rate of children in the United States has decreased over the past
two decades, much of this was due to a decline in deaths from natural causes
whereas traumatic causes have increased in children.
Vital and colleagues use the 1997 Kids Inpatient Data Base (KID) to exam-
ine orthopedic trauma as it occurred in a national pediatric inpatient popula-
tion. They noted that a femur fracture was the most common reason for hospi- Percent of Fractures in
talizing a child with a musculoskeletal injury, followed by tibial-fibular fracture Males (vs. Females)
and humerus fracture (including distal elbow fractures). Closed supracondylar
fractures accounted for 59% of all humerus fractures. Next in frequency for ad- Hand and finger—78%
mission were fractures of the radius and ulna followed by vertebral fractures, Forearm—72%
pelvic fractures, and hand fractures (hand fractures are very common but few Tibia, fibula—71%
require hospital admission). Femur—71%

Gender Issues Galano,Vitale et al.

In support of the general sense that males are likely to participate in more risky
activities, Vitale et al. found that 78% of hand and finger fractures, 72% of
forearm fractures, 71% of tibia and fibular fractures, 71% of femoral fractures,
58% of humeral fractures and 56% of vertebral fractures occurred in males.
The only type of fracture to have a higher incidence in females were pelvic frac-
tures, but this was by only a miniscule amount (50.1% female—49.9% male).
This clear gender disparity, with males were more likely to sustain orthopedic
injuries, was proposed to be due to participation in high-injury contact sports
such as football and hockey (Fig. 20-12). Also, extreme motorized sports, bicy-
cling sports, skateboarding sports, etc., are pursued more aggressively by males.
Interestingly, when one gets to the college athletic level, with a specific focus
on anterior cruciate ligament injuries, the female to male ratio reverses with an
anterior cruciate ligament injury ratio 2:1 for college soccer and 8:1 for college
basketball. These are related to male to female anatomic differences in the
human knee (shape of the intercondylar notch) as well as hormonal issues and
training techniques that make female college athletes at great risk for knee liga-
ment injuries.

MANDATED SPORT FOR EVERY CHILD—

RISKS AND BENEFITS
The idea that all children should participate in vigorous physical education and
Figure 20-12. Sport for females has been
pursue sports during their growing years has been historically powerful in ad- a great 20th (and 21st) century advance.
vanced cultures, suffering a fall-off in the 1960s and 1970s but has been re- The increase risk for ligament injury (knee)
cently revived. In the United States Title IX legislation, mandating sport oppor- was a bit of a cultural surprise. (Photo
tunity equality, greatly increasing female participation. courtesy of L. Manhiem.)
302
Accident Prevention, Risk and the
Evolving Epidemiology of Fractures
Figure 20-13. Obesity and poor condi-
tioning, followed by mandatory sport, is a
recipe to predict fracture. This vicious
cycle is hard to break. In Arkansas, all chil-
dren are weighed by the school, with an-
nual reports to their parents.This may be a
start toward reversing our epidemic of
childhood obesity.
Figure 20-14. A child’s love for risk is
part of the genetic code. Lacking war, hunt-
ing, and other primitive human experi-
ences, modern youth will try a motorcycle.
(Photo courtesy of R. Knudson.)
Organizations such as the President’s Physical Fitness Counsel (chaired in
the George H. W. Bush administration by the now legendary Arnold
Schwarzenegger) have made Americans aware of the benefits of keeping their
children fit. Concern about childhood obesity is one reason for the recent re-
vival of attention to childhood physical fitness. The benefit of sport for girls has
also been clearly established (less drug use, less teenage pregnancy, better self-
esteem).
CHILDHOOD OBESITY AND
FRACTURE RISK
Childhood inactivity and obesity are likely related to television-watching,
video game use, and parents driving their children everywhere, including to
school, combined with too much of the wrong type of food (fat, sugar, “fast
food”). The rather sudden forcing of obese, out-of-shape children into vigor-
ous sports appears to be increasing the risk for injury to children in our center
(Fig. 20-13).
Obesity and risk for injury (especially knee and ankle fractures) is a growing
problem. The state of Arkansas has mandated that all school children have their
weight (plus adjusted body mass index [BMI]) measured at school annually
with the parents given a report (see Suggested Readings—Wall St. Journal).
This seems a positive step towards public awareness of the devastating effect
that obesity has on a child (limits social and sport opportunity; increases risk for
musculoskeletal problems, diabetes, hypertension).
Aerobic training and athletic effort are wonderful but should be started early
in life and continued on a regular pace. Often, the opposite is true for obese
children whose parents have been unable to provide good nutritional or athletic
advice early in life. When these children encounter demanding physical educa-
tion teachers, their lack of conditioning increases their risk for musculoskeletal
injury.
The risk for the ankle, knee, and hip injury in a 110-kg adolescent girl with
increased femoral torsion, increased genu valgum, lateralization of the patella,
and “weak ankles” is profound. Yet we still describe it as an “accident” (rather
than an almost predictable event, considering the combined factors).
Orthopedic surgeons should take the lead in educating parents regarding the
importance of conditioning and preparation for physical education training
and sports. For example, there is little lay knowledge of the increased risk for
the development of femoral retroversion and then slipped capital femoral epi-
physis (a potentially life-changing event—avascular necrosis [AVN] of the hip)
in the obese child. Publicly sponsored evening advertising spots on television re-
garding obesity, slipped epiphyses, and the global musculoskeletal consequences
of obesity would be a great advance.
Value of Sport—Later Life Benefits
It is important to understand the benefit of physical activity and risk in the
musculoskeletal and neurologic development of a child (Fig. 20-14). With rou-
tine use of skateboards, snowboards, and other devices, the contemporary child
(particularly those raised in sunny California which allows year-round activity)
may have the best sense of balance and body control of all modern humans
(primeval jungle life likely provided the same benefit). This sense of balance and
love for physical activity will likely benefit them in many ways in later life in-
cluding sport participation into the middle and upper years.
SUMMARY 303
Suggested Readings
Children’s fracture epidemiology is changing in advanced cultures. It would ap-
pear that the incidence of children's fractures is increasing rather than decreas-
ing due to cultural trends including crowded cities, motorized vehicles, partici-
pation in aggressive formal sports, and massive participation in unorganized “This sense of balance and
extreme athletic activity. love for physical activity will
The concept of risk homeostasis may be partially responsible, with the safety
benefits of better equipment, rules, and regulations being outrun by increased likely benefit them in many
speed and risk (to satisfy a human need). ways in later life including
Along with developing better methods for treating such injuries, the ortho-
pedic surgeon community should continue to be active in educating and advis-
sport participation into the
ing the government regarding protective measures to minimize the burden of middle and upper years”
musculoskeletal trauma. It is unlikely that the fracture incidence will decrease;
therefore the medical system (and orthopedic community) should continue re-
search on effective, efficient treatment methods. It is hoped that this text will
contribute to this effort.

Suggested Readings
Brent, R., Weitzman, M: The Pediatricians
Role and Responsibility in Educating
Parents about Environmental Risks; Pedi-
atrics, 113:4. 1167–1172, 2004.
Cheng J, Ng B, Ying S, Lam D. A 10 year
study of the changes in the pattern and
treatment of 6,493 fractures. J Pediatr
Orhop 19:344–350, 1999.
Galano, G., Vital, M.A., Kessler, M., Hyman,
J., Vital, M.G: The Most Frequent Trau-
matic Orthopedic Injuries From a Na-
tional Pediatric Inpatient Population. J.
Pediatr. Orthop, 2004 (in press)
Heyworth, B., Galano, G., Vitale, M.A.,
Vitale, M.G: Management of Closed
Femoral Fractures in Children Age 6
to 10. J. Pediatr. Orthop. 24:455–459,
2004.
Kiely PD,Kiely PJ, Stephens MM, Dowling
FE. Atypical distal radial fractures in chil-
dren. J Pediatr Orthop(B) 13:202–205.
2004.
Khosla S, Melton LJ 3rd, Dekutoski MB,
Achenbach SJ, Oberg AL, Riggs BL. Inci-
dence of Childhood Distal Forearm Frac-
tures Over 30 Years—A Population Based
Study. JAMA, 2003 Sep 17;290(11):
1479–85.
McKay B. “Weigh-In” of Arkansas children
sparks more fears over obesity. Wall St.
Journal Sept. 8, 2004.
 Coda
OTHER TEXTS
Ours is a basic text that covers common problems. To see the future, we have
stood on the shoulders of giants. These “giants” are the comprehensive chil-
dren’s fracture texts from around the world that have helped us to understand
the nuances of fracture care. We present a short list.
1. Benson MKD, Fixsen JA, Macnicol MF (eds) Children’s Orthopaedics and
Fractures. London: Churchill Livingston, 1994.
2. Blount WL Fractures in Children. Baltimore: Williams and Wilkins, 1955.
3. Dimeglio A, Herisson C, Simon P: Les Traumatismes de l’enfant et leurs
sequelles. Paris: Masson, 1993.
4. Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, 3rd ed.
Philadelphia: Saunders, 2003.
5. Letts RM (ed): Management of Pediatric Fractures. New York; Churchill
Livingstone, 1994.
6. MacEwen HF, Kasser JR, Heinrich SD (eds): Pediatric Fractures: A Practi-
cal Approach to Assessment and Treatment. Philadelphia: Williams and
Wilkins, 1993.
7. Hefti F: Kinderorthopadie in der Praxis. Springer; Berlin, 1998.
8. Metaizeau JP. Osteosynthese Chez L’enfant. Montperlier: Sauramps Ed,
1988.
9. Morrissy RM and Weinstein S (eds): Pediatric Orthopaedics, 5th ed.
Philadelphia: Lippincott, 2001.
10. Ogden JA: Skeletal Injury in the Child. Philadelphia: Lea and Febiger, 3rd
ed. 2000
11. Rang M: The Growth Plate and its Disorders. Baltimore: Williams and
Wilkins, 1969.
12. Rang M: Children’s Fractures, 2nd ed. Philadelphia: Lippincott, 1983.
13. Rockwood CA Jr, Wilkins KA, Beaty KH (eds): Fractures in Children, 5th
ed. Philadelphia: Lippincott-Raven, 2001.
14. Sharrard WJW: Paediatric Orthopaedics and Fractures. Oxford: Blackwell,
1971.
15. Tachdjian M: Pediatric Orthopaedics (J. Herring, editor, 3rd ed). Philadel-
phia: Saunders, 2002.
16. Von Laer L: Pediatric Fractures and Dislocations. New York: Georg
Thieme Verlag, 2004.
17. Weber BG, Brunner C, Freuler F: Die Frakturenbehandlung bei Kindern
und Jugendlichen. Berlin: Springer-Verlag, 1978.
We thank these authors for their immense contributions. We also apologize for
not listing other texts that are also available. We would simply state that “if you
can’t find it in this list, it likely doesn’t exist.”

MR
MP
DW

305
 Index
Accidents Bicycling injuries, 286 swimming (Gore-Tex), 71
prevention of, 293–300 Biomechanics ulceration, 69, 71–72
vehicular bone, 2 upper extremity, 60–63
prevention, 295–296 periosteal, 7 vascular complications, 278–280. See also
Waddell’s triad, 288 Birth injuries Compartment syndromes
Acetabular fractures, 178 clavicle, 76, 79 wedging, 67–69
classification, 178 shoulder, 87 Cerebral palsy, pathologic fractures in,
radiography, 175–176 Bivalve casts, 51, 56, 58–59 286–287
treatment, 178 Bone Cervical collar, 256, 259
Acromial fractures, 93–94 biomechanics, 2 Cervical spine injuries, 261–263. See also
Analgesia, for reduction, 47–48 growth plate, 4 Spinal injuries
Anatomic considerations, 1 overgrowth, 8 radiography, 259–260
terminology, 27–28 physiology, 7–10 Chance fractures, 265
Anatomic planes, 27–32 progressive deformity, 8 Child abuse, 280–285
Anesthesia, 47–48 remodeling, 7–8 management, 283
Aneurysm, posttraumatic, 274 traumatic bowing, 2–3 Munchausen by proxy syndrome, 283
Ankle injuries, 227–241 Bone cyst, pathologic fractures and, 285–286 by other children, 283
anatomic aspects, 228 Bony bridging, physeal, 24 overdiagnosis, 283–284
classification, 229–230 Boxer’s fracture, 157–159 recognition, 281–283
Kump’s bump, 234 Brace reporting, 283
malleolar fractures, 235 figure-of-eight, 79–80 spinal injuries, 267
nonarticular gunslinger, 89 transphyseal distal humeral fractures, 102
extensor retinaculum syndrome, 234 Sarmiento, 89, 92 Clavicle fractures, 75–83
perichondrial ring ablation, 234–235 Brachial plexus injury, 76 anatomic aspects, 76
pitfalls, 233–234 Buckle fractures, 2 birth injury, 76, 79
Salter-Harris Type I tibial, 231 Butterfly fractures, 5 classification, 77–79
Salter-Harris Type II tibial, 231–235 complications, 82–83
radiography, 228–229 Calcaneal fractures, 249 diagnosis, 76–77
sprains, 241 Calcium deficiency, 298 follow-up, 80
syndesmosis, 240–241 Car accidents lateral, 80
Tillaux fractures, 235 injury prevention, 295–296 malunion/nonunion, 82
triplane fractures, 235–238 Waddell’s triad, 288 medial, 8081
Anterior cruciate ligament injuries, 204, Carpal fractures, 157–159 neonatal, 76, 79
212–213 Carpal navicular fractures, 160–161 outcome, 83
Anterior drawer test, 204 Casts, 53–73. See also specific injuries radiography, 77
Apprehension test (Fairbank sign), 204 application, 51, 55–58 treatment, 79–82
Arterial injuries. See Vascular complications bivalve, 51, 56, 58–59 Communication with family
Aspiration, of hemarthrosis, 202–203 complications, 69–73 medical jargon, 34–36
Athletic injuries, 296–300 dorsiflexion crinkle, 72, 73 urgent reduction, 38–39
Atlanto-axial fracture/dislocations, 261 duration, 55 Compartment syndromes, 278–280. See also
Atlanto-axial instability, 254 equipment, 56, 59–60 Vascular complications
Atlanto-axial rotary subluxation, 262 ergonomics, 57–58 diagnosis, 278–279
Automobile accidents foreign bodies, 71 differential diagnosis, 279
injury prevention, 295–296 hanging arm, 89 lower limb, 280
Waddell’s triad, 288 hip-knee flexion, 69, 187–188 treatment, 279–280
Avulsion injuries hip spica. See Hip spica casts upper limb, 98, 109–110, 280
hip, 172 history, 54–55 Complete fractures, 3
knee, 205 lower extremity, 64–67 Compression test, in pelvic fractures, 166
osteochondral fragments, 12 materials, 55, 71 Conscious sedation, 49–50
pelvis, 176–178 molding, 57 Continuous passive motion, 16
physeal, 12 padding, 56 Coracoid fractures, 93–94
Axial plane, 28, 29 poorly designed, 72–73 Coranoid fractures, 130–131
removal, 59–60 Coronal plane, 27–28, 29, 30
Bandage, Velpau, 89, 92 rolling technique, 56–57 Crush injuries
Bankart lesion, 87 showering/bathing, 71 bicycle spoke, 224
Bathing, with cast, 71 spacers, 51, 58 foot/ankle, 224
Bicycle spoke injuries, 224 splitting, 51, 56, 58–59 hand, 162
307
308
Index

Cubitus valgus, 128 family education, 38–39 mid-shaft fractures, 187

Cubitus varus, 102, 103, 112 follow-up, 52
Cuboid fractures, 248–249 indications, 36–38
Cultural aspects, 299 initial assessment, 44
Cuneiform fractures, 248–249 local anesthesia, 48
Cysts, pathologic fractures and, 285–286 nurse practitioners in, 43
nurse triage, 44
Deformity, progressive, 8 orthopedic assessment, 46
Discoid meniscus, 212 orthopedic residents in, 42–43
Dislocations overview, 41–42
atlanto-axial, 261 physician assistants in, 43
elbow, 87–88, 131–134 post-reduction events, 51–52
hip, 167–169 protocol, 43–47
knee, 203–205 regional anesthesia, 49
Monteggia, 131–134 treatment strategy, 46
patellar, 205 Epiphyseal stapling, 199
radial head, 131–134 Epiphysiodesis, femoral, 199
sacroiliac, 166 Epiphysis. See also Physis
shoulder, 87–88 blood supply, 13–14
subtalar, 249 fractures, 6, 11–12
thumb, 159–160 healing reaction, 14–16
Dorsal, 32 slipped capital femoral, 173–174
Dorsiflexion crinkle, 72, 73 terminology, 6
Erb’s palsy, 76
Elbow injuries, 95–134 External fixation, femoral, 196
anatomic aspects, 96, 119–134 Extra-octave fracture, 156
compartment syndrome, 98, 109–111,
280 Fairbank sign, 204
coranoid fractures, 130–131 Falls
diagnosis, 96–100 child abuse, 281–282
dislocations, 122–124 prevention, 295
distal humerus, 95–118 Family education
initial assessment, 96–98, 120 medical jargon, 34–36
lateral condyle fractures, 112–115 urgent reduction, 38–39
lateral epicondyle fractures, 118 Fasciotomy, 280
medial condyle fractures, 115–116 Femoral fractures
medial epicondyle fractures, 116–118 distal, 188, 207–209
Monteggia fracture/dislocations, 131–134 head, 169–174. See also Hip injuries
nerve injuries, 97–98, 109 shaft. See Femoral shaft fractures
olecranon fractures, 128–130 Femoral shaft fractures, 181–199
proximal radius and ulna, 119–135 classification, 183–184
proximal ulnar fractures, 128–134 diagnosis, 181–182
pulled elbow syndrome, 121–122 open, 196
radial head and neck fractures, 124–128 radiography, 182–183
radiography, 98–100, 120–121 treatment
supracondylar fractures, 102–112. See also acceptable results, 197–199
Supracondylar fractures cast position, 187–188
transphyseal distal humerus fractures, children age 0-2 years, 184–185
100–102 children age 2-6 years, 185–190
vascular status, 98, 109–111 children age 6-12, 190–193
Volkmann’s contracture, 98 children age 14 and older, 193
Emergency reduction, 41–52 distal fractures, 188, 207–209
arrival at ED, 43 duration, 188
cast application, 51. See also Casts epiphyseal stapling, 199
conscious sedation, 49–50 epiphysiodesis, 199
current trends, 42 external fixation, 196
developments, 41–42 flexible nail, 191–193
in ED vs. OR, 46–47 intramedullary rod, 193, 194
family considerations, 38–39 limb length discrepancy, 197–199
open fractures, 196
outcome, 197–199
pitfalls, 188
proximal fractures, 187
return to activity, 190
skeletal traction, 186
skin traction, 186
spica cast, 185–187, 188, 189
submuscular plate, 195, 196
Fibroma, nonossifying, pathologic fractures
and, 286
Fibula
intact, tibial fractures with, 222
Salter-Harris Type I/II fractures, 231
Figure-of-eight brace, 79–80
Fixation methods. See specific fractures
Flexible nail
femoral shaft fractures, 191–193
humerus shaft fractures, 145–148
tibial shaft fractures, 221–222
Floating knee, 224
Foot injuries, 243–251
calcaneal fractures, 249
Lisfranc, 247–248
metatarsal fractures, 245–247
midfoot, 248–249
phalangeal fractures, 243–245
Pseudomonas osteomyelitis, 251
puncture wounds, 251
subtalar dislocations, 249
talar fractures, 250–251
tarsometatarsal, 247–248
terminology, 33–34
Forearm fractures, 135–150
anatomic aspects, 136
distal
above physis, 140–143
buckle, 140–141
complete (both bones), 140–141
Galeazzi’s, 143
physeal, 139–140
reduction, 141–142
solitary, 143
initial assessment, 137
malunion, 149
midshaft, 143–148
flexible nailing, 145–148
greenstick, 143–144
plastic deformation, 144
reduction, 144–148
pathology, 136
radiography, 137–139
refracture, 149
remodeling, 148
treatment, 38
Foreign bodies, under cast, 71
Fractures. See specific types and sites
Frontal plane, 27–28, 29, 30
 309
Index

Galeazzi’s fracture, 143 treatment, 169–173 Lisfranc injury, 247–248

Gamekeeper’s thumb, 159 vs. slipped capital femoral epiphysis, Local anesthesia, 48
Gender issues, 301 173–174 Lower limb
Gillespie fractures, 223–224 initial assessment, 165–166 compartment syndromes, 280
Glenoid fractures, 94 Hip-knee flexion casts, 69, 187–188 length discrepancy prediction,
Gore-Tex casts, 71 Hip spica casts, 69–70, 185 197–199
Greater tuberosity fractures, proximal application, 189 terminology, 32–33
humerus, 92 duration, 188
Great toe fractures, 243–245 indications, 69–70, 185 Malleolar fractures, 235–240
Green-Anderson method, for limb length Humerus fractures. See also Elbow injuries; Mallet finger, 153–155
prediction, 198, 199 Shoulder injuries Malunion, 8, 32–34. See also specific fractures
Greenstick fractures, 3 proximal, 88–92 cast wedging, 67–69
proximal humerus, 92 classification, 88 terminology, 32–34
tibial, 218 greater tuberosity, 92 March fractures, 247
Growth plate. See Physis greenstick, 92 McMurray test, 204
Growth remodeling, 7–8 lesser tuberosity, 92 Medial collateral ligament injuries, 212
Gunslinger brace, 89 malunion risk, 90–92 Medial condyle fractures, 115–116
Gunstock deformity, 110 outcome, 92 Medial epicondyle fractures, 116–118
reduction, 90–92 Melbourne method, for limb length predic-
Hand injuries, 151–162 treatment, 88 tion, 198, 199
assessment, 152 shaft, 92–93 Meniscus tears, 211–212
carpal fractures, 157–159 transphyseal distal, 100–102 Metacarpal fractures, 157
crush, 162 Metatarsal fractures, 245–247
initial management, 152–153 Immobilizer, shoulder, 89 fifth metatarsal base, 246
metacarpal fractures, 157–159 Intramedullary fixation. See also specific first metatarsal, 246
nerve, 162 fractures Jones, 246–247
phalangeal fractures, 153–157. See also physis and, 16 multiple, 245–246
Phalangeal fractures shaft and neck, 245
radiography, 152 Jones fractures, 246–247 stress, 247
surgical indications, 153 Monteggia fracture/dislocations, 131–134
tendon, 162 Klippel-Feil syndrome, 254 Munchausen by proxy syndrome, 283
terminology, 152 Knee, floating, 224 Muscular dystrophy, pathologic fractures in,
thumb, 159–160 Knee injuries, 201–213 287
Hanging arm cast, 89 diagnosis, 202–204
Hangman fractures, 262–263 distal femur fractures, 188, 207–209 Nancy nail
Head trauma, 288 hemarthrosis, 201–203 femoral shaft fractures, 191–193
Healing rate, 9 joint dislocation, 203–205 humerus shaft fractures, 145–148
Hemarthrosis, in knee injuries, 201–203 ligament, 204, 212–213 tibial shaft fractures, 221–222
Hemophilia, 289 meniscus, 211–212 Navicular fractures, 248–249
Hemorrhage, in pelvic fractures, 167 overview, 201–202 Nerve injuries. See also Compartment
Herzenberg-Paley method, for limb length patellar dislocation, 205 syndromes
prediction, 198, 199 patellar fractures, 206–207 brachial plexus, 76
Hill-Sachs lesion, 87 proximal tibial fractures, 209–211 Erb’s palsy, 76
Hip, snapping, 169 radiography, 203 hand, 162
Hip injuries, 165–174 Kump’s bump, 234 pelvic fractures, 166
dislocations, 167–169 K wires. See specific fractures radial nerve, 93
fractures, 169–174 ulnar nerve, 97–98, 109, 123–124
anatomy and physiology, 169 Lachman test, 204 upper extremity
avulsion, 172 Lateral collateral ligament injuries, 212 assessment, 97
cervicotrochanteric (type III), 170–172 Lateral condyle fractures, 112–115 supracondylar fractures, 103
classification, 169 Lateral epicondyle fractures, 118 Volkmann’s contracture, 98
complications, 173 Lauge-Hansen classification, of ankle frac- Neuromuscular disorders, pathologic frac-
displaced, 171–172 tures, 230 tures in, 286
greater trochanter, 172 Lesser tuberosity fractures, proximal Newborn, fractures in, 289
intertrochanteric (type IV), 172 humerus, 92 clavicular, 76, 79
lesser trochanter, 172 Ligament injuries shoulder, 87
nondisplaced, 171 ankle, 241 90-90 casts, 69, 187–188
transcervical (type II), 170–172 knee, 204, 212–213 Nonossifying fibroma, pathologic fractures
transphyseal (type I), 169–170, 173 wrist, 161–162 and, 286
310
Index

Nonunion, 8. See also specific fractures cartilage defects, 16 assessment, 85–86

Nursemaid’s elbow, 121–122 classification, 16–21 dislocation, 87–88
internal fixation, 16 humeral shaft fractures, 92–93
Obesity, 302 management, 21–24 neonatal, 86
Oblique fractures, 4 stress, 21 proximal humerus fractures, 88–92
Odontoid fractures, 262 tibial fractures, 215–217 radiography, 86
Olecranon fractures, 128–130 surgical closure, 199 scapular fractures, 93–94
Open fractures, treatment, 37 Pin fixation. See specific fractures Showering, with cast, 71
Os calcis fractures, 250 Pivot shift test, 204 Skin traction, 186
Osgood-Schlatter disease, 210 Planes, descriptive, 27–32 Skin ulcers, under cast, 69, 71–72
Os odontoideum, 254–255 Plate, submuscular, for femoral shaft frac- Slings
Osteochondral fragments, 12 ture, 195, 196 clavicle fractures, 79–80
Osteodystrophy, renal, 289 Playground injuries, 296–297 proximal humerus fractures, 88, 89
Osteogenesis imperfecta, pathologic frac- Posterior cruciate ligament injuries, 204, Slipped capital femoral epiphysis, 173–174
tures in, 288 213 Snapping hip, 169
Osteomyelitis, of foot, 251 Posterior drawer test, 204 Spacers, cast, 51, 58
Osteopetrosis, pathologic fractures in, 288 Posterior splints, 67 Spica casts. See Hip spica casts
Os trigonum, 251 Power tools, 297 Spina bifida, pathologic fractures in 287–288
Overgrowth, 8 Preventive measures, 293–300 Spinal cord injury, 267–269
Progressive deformity, 8 without radiographic abnormality, 254,
Paraplegia Pseudomonas osteomyelitis, of foot, 251 268–269
pathologic fractures, 287–288 Pulled elbow syndrome, 121–122 Spinal injuries, 253–269
tibial fractures, 224 Puncture wounds, of foot, 251 anatomic aspects, 254–255
Patella atlanto-axial, 261
dislocations, 205 Quadriceps active test, 204 atlanto-axial instability, 254
fractures, 206–207 atlanto-axial rotary subluxation, 262
Pathologic fractures, 285–288 Radial head and neck fractures, 124–128 atlas fractures, 261
Pedestrian injuries, 288 Radial head dislocations, 131–134 burst fractures, 263–264
Pediatric trauma, analysis of, 300–301 Radial nerve injury, in humeral shaft frac- cervical spine, 261–263
Pelvic fractures, 174–178 tures, 93 radiography, 259–260
acetabular, 178 Radiographs. See also specific injuries Chance fractures, 265
associated injuries, 166 stress, 216 compression fractures, 263–264
avulsion, 176–178 Radius injuries etiology, 253
blood loss, 167 radial head and neck fractures, 124–128 hangman fractures, 262–263
classification, 176 radial head dislocations, 131–134 immobilization, 256, 259
initial assessment, 165–166 shaft, 135–150. See also Forearm fractures initial assessment, 255–256, 258
nerve injuries, 166 Recurvatum, 32 level of, 254
pelvic ring, 178 Reduction. See Emergency reduction and nonaccidental, 267
radiography, 167, 175–176 specific fractures odontoid fractures, 262
sacroiliac dislocation, 166 Refracture, 9–10, 298 os odontoideum, 254–255
treatment, 176–178 Regional anesthesia, 49 overview, 253–256
Periosteal biomechanics, 7 Remodeling, 7–8 radiography, 254–260
Phalangeal fractures, 243–245. See also Renal dystrophy, 289 normal variants, 254–255
Hand injuries Rickets, 289 ring apophysis fractures, 266
distal, 153–155 Risk homeostasis, 299–300 spinal cord injury, 267–269
extra-octave, 156 without radiographic abnormality, 254,
intra-articular, 157 Sacroiliac dislocation, 166 268–269
mallet finger, 153–155 Sagittal plane, 28, 29, 30–32 spondylolysis/spondylolisthesis, 266–267
neck, 155 Salter-Harris classification, 16–21. See also thoracic/lumbar, 263–266
proximal, 156 specific fractures radiography, 260
shaft, 155–156 Sarmiento brace, 89, 92 treatment, 260–261
Phemister method, for epiphysiodesis, 199 Sartorius avulsion, 177–178 Spiral fractures, 3
Physiologic considerations, 7–10 Saw, cast, 59–60 humeral shaft, 92–93
Physis, 4, 5–7, 8. See also Epiphysis Scaphoid fractures, 160–161 Splints
anatomy, 13 Scapula fractures, 93–94. See also Shoulder lower extremity, 67
avulsion injury, 12 injuries suspension tape, for mallet finger, 154
healing reaction, 14–16 Shoulder immobilizer, 89 ulnar gutter, 153
injuries, 12–14 Shoulder injuries, 85–94 Split casts, 51, 56, 58–59
bony bridging, 24 anatomic aspects, 86 Spondylolysis/spondylolisthesis, 266–267

Sports injuries, 296–300
Sprains, ankle, 241
Stapling, epiphyseal, 199
Stress fractures, 290
metatarsal, 247
physeal, 21
tibial, 224
Stress radiographs, 216
Subluxation, atlanto-axial rotary, 262
Submuscular plate, for femoral shaft frac-
ture, 195, 196
Subtalar dislocations, 249
Supracondylar fractures, 102–112
classification, 103, 104
complications, 109–112
initial management, 103
malunion, 110
mechanics, 102
nerve injuries, 103
percutaneous pinning, 105, 107–108
postoperative care, 109
pulseless arm, 109–111
reduction, 106
treatment, 37–38
type I, 103–105
type II, 104, 105–108
type III, 104, 108–112
Suspension taping, for mallet finger, 154
Swimming casts, 71
Syndesmosis injuries, 240–241
Talar fractures, 250–251
Taping, suspension, for mallet finger, 154
Tarsometatarsal injuries, 247–248
Tendon injuries, hand, 162
Tensor fascia avulsion, 177–178
Terminology, 2–5, 27–36
anatomic, 27–32
communication with family, 34–36
hand surgery, 152
orthopedic, 28–36
physis/epiphyis, 6
treatment implications, 36
Thrombosis, posttraumatic, 274
Thumb injuries, 159–160
Tibial fractures, 215–225
bicycle spoke, 224
common variations, 222–225
diaphyseal (midshaft), 219–222,
223–224
displaced, 216–217
distal. See also Ankle injuries
diaphyseal, 223–224
metaphyseal, 225
nonarticular, 231–235
floating knee, 224
Gillespie, 223–224
intact fibula, 222
open, 223
in paraplegics, 224
proximal, 209–211
arterial hazard, 217–218
growth plate injuries, 215–217
metaphyseal, 217–219
progressive valgus, 219
tibial spine, 209–210
tubercle, 210–211
valgus greenstick, 218
radiography, 216
stress, 225
toddler’s, 223
vascular complications, 217–218
Tillaux fractures, 235
Toddler’s fracture, tibial, 223
Toe fractures, 243–245
Traction
skeletal, 186
skin, 186
supracondylar fractures, 108
vascular complications, 274
Transphyseal distal humerus fractures,
100–102
Transverse fractures, 5
Transverse plane, 28, 29, 30–32
Traumatic bowing of bone, 2–3
Triplane fractures, 235–238
311
Index
Ulcers, under cast, 69, 71–72
Ulnar injuries. See also Elbow injuries; Fore-
arm fractures
coranoid fractures, 130–131
Monteggia fracture/dislocations,
131–134
olecranon fractures, 128–130
proximal ulna, 128–134
Ulnar nerve injuries, 97–98, 109, 123–124
Univalve casts, 51, 56, 58–59
Urgent reduction. See Emergency reduction
Valgus stress test, 204
Varus stress test, 204
Varus/valgus, 28, 30, 31
Vascular complications, 271–278
arterial lesions, 274
arterial occlusion, 272–273
compartment syndromes, 278–280. See
also Compartment syndromes
diagnosis, 272
elbow injuries, 98, 109–110
fracture sites, 273
pathophysiology, 272–273
pelvic fractures, 166
prevention, 273
pulseless arm, 109–111
supracondylar fractures, 98, 109–111
tibial fractures, 217–218
treatment, 273–278
Vehicular accidents
injury prevention, 295–296
Waddell’s triad, 288
Velpau bandage, 89, 92
Ventral, 32
Volkmann’s contracture, 98
Waddell’s triad, 288
Wire fixation. See specific fractures
Wrist injuries. See also under Forearm;
Radius
ligament, 161–162
scaphoid fractures, 160–161